A nurse is assessing a group of clients at risk of developing a pressure injury. The nurse should identify that which of the following clients is at the greatest risk?

A client who has dementia and is incontinent of urine

A client who is 2 days postoperative following orthopedic surgery

A client who has a T-tube following an open cholecystectomy

A client who has had a recent myocardial infarction

Answer and Explanation

The Correct Answer is A

Rationale:

A. A client who has dementia and is incontinent of urine: This client has multiple contributing factors, cognitive impairment limits repositioning and self-care, while urinary incontinence increases skin moisture and maceration, promoting skin breakdown and pressure injury formation.

B. A client who is 2 days postoperative following orthopedic surgery: Although this client may have limited mobility, they are typically on a monitored recovery path with interventions like repositioning, early ambulation, and pain management, reducing their overall risk.

C. A client who has a T-tube following an open cholecystectomy: This client is generally alert, mobile with assistance, and able to communicate needs, which lowers their risk of pressure injury compared to more dependent individuals.

D. A client who has had a recent myocardial infarction: This client may be monitored in bed rest initially, but cardiovascular stability and mobility often improve quickly with treatment, making their pressure injury risk moderate rather than the highest among the group.

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Correct Answer is C

Explanation

Rationale:

A. "I will remove gluten from my diet.": Gluten is unrelated to latex allergies. It is typically avoided in conditions like celiac disease, but does not cross-react with latex proteins and is not a concern for latex-sensitive individuals.

B. "I will remove peanuts from my diet.": Although peanut allergies are common, there is no significant cross-reactivity between peanuts and latex. Avoiding peanuts is not necessary unless the client has a separate peanut allergy.

C. "I will remove bananas from my diet.": Bananas contain proteins similar to those found in natural latex. Clients with latex allergies often have cross-reactive food allergies, especially to bananas, avocados, kiwis, and chestnuts this is known as latex-fruit syndrome.

D. "I will remove dairy products from my diet.": Dairy products are not associated with latex sensitivity. Removing them offers no protective benefit for clients with a latex allergy unless a separate dairy intolerance or allergy exists.

A. "You should expect your blisters to last up to three weeks." B. "Antiviral medications are most effective if taken within the first 72 hours of symptoms." C. "People who have had chicken pox are at a decreased risk for herpes zoster” D. "Severe pain after the blisters are gone is less common in older adults."

Correct Answer is B

Explanation

Rationale:

A. "You should expect your blisters to last up to three weeks.": Herpes zoster lesions typically last 7 to 10 days, with crusting and healing often occurring within 2 weeks. While some cases may extend slightly longer, stating "up to three weeks" may overgeneralize and mislead.

B. "Antiviral medications are most effective if taken within the first 72 hours of symptoms.": Antiviral drugs like acyclovir or valacyclovir are most effective when initiated within 72 hours of symptom onset. Early treatment reduces severity, duration, and the risk of complications such as postherpetic neuralgia.

C. "People who have had chicken pox are at a decreased risk for herpes zoster.": Herpes zoster occurs due to reactivation of the varicella-zoster virus, which remains dormant after chickenpox. Therefore, individuals who have had chickenpox are actually at increased risk.

D. "Severe pain after the blisters are gone is less common in older adults.": Older adults are more likely to experience postherpetic neuralgia, a complication involving persistent nerve pain after lesions resolve. The risk and severity of this pain increase with age, not decrease.

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A nurse is assessing a group of clients at risk of developing a pressure injury. The nurse should identify that which of the following clients is at the greatest risk?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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