A nurse is assessing clients for skin integrity. Which of the following clients is at greatest risk for developing skin breakdown?

A client who has occasional urinary incontinence

A client who has inadequate nutrition

A client who has moderate Alzheimer's disease

A client who is paraplegic

Answer and Explanation

The Correct Answer is D

D. Paraplegia significantly increases the risk of skin breakdown due to immobility, lack of sensation, and prolonged pressure on specific areas of the body. These clients require meticulous skin care and frequent repositioning to prevent pressure injuries.

A While urinary incontinence can contribute to skin breakdown, especially if not managed properly, it may not pose as great a risk compared to other factors like poor nutrition or immobility.

B. Poor nutrition compromises skin integrity by reducing the skin's ability to repair and maintain itself, making it more susceptible to breakdown. This factor significantly increases the risk of developing pressure ulcers and other skin lesions.

C. Clients with Alzheimer's disease may have increased risk due to various factors such as mobility issues, impaired sensation, and difficulty with self-care. However, the degree of risk can vary depending on the stage of the disease and individual circumstances.

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Correct Answer is B

Explanation

B. HbA1c is considered the gold standard for assessing long-term glycemic control in individuals with diabetes. It provides an overall picture of how well blood sugar levels have been controlled over the preceding 2-3 months, helping healthcare providers adjust treatment plans as needed.

A Postprandial (after-meal) blood glucose levels indicate how well blood sugar levels are controlled after eating. While important for immediate assessment of glucose management after meals, it does not provide a comprehensive view of long-term glycemic control.

C. While fasting blood glucose levels are important in daily diabetes management, they do not provide the extended timeframe assessment that HbA1c does for long-term control.

D. OGTT results are not typically used to monitor long-term glycemic control in individuals with established diabetes mellitus. It assesses how the body responds to a glucose load and is not as practical or common for routine monitoring compared to HbA1c.

A. "Did you decrease your insulin intake before you exercised?" B. "It is normal to feel this way after a morning run." C. "Were you careful to not have carbohydrates after the run?" D. "It becomes easier when exercise is a routine."

Correct Answer is A

Explanation

A This response addresses a potential cause of exercise-induced hypoglycemia. Clients with type 1 diabetes often need to adjust their insulin dose or carbohydrate intake before exercise to prevent hypoglycemia. Asking about insulin adjustment is relevant to assess whether the client took appropriate precautions.

B. While exercise can cause fatigue, feeling diaphoretic, having palpitations, and extreme exhaustion are not normal responses after exercise, especially for someone with type 1 diabetes. This response does not address the potential cause of the symptoms.

C. This response addresses the importance of carbohydrate intake post-exercise to prevent or treat hypoglycemia. It encourages the client to reflect on their dietary choices following exercise, which can impact blood glucose levels.

D. While establishing a routine for exercise is beneficial for managing diabetes, this response does not address the immediate concern of hypoglycemia or provide guidance on managing the client's current symptoms.

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A nurse is assessing clients for skin integrity. Which of the following clients is at greatest risk for developing skin breakdown?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months. Which of the following laboratory results should the nurse monitor to determine long- term glycemic control?

Correct Answer is B

Explanation

A nurse in a clinic is assessing a client who has type 1 diabetes mellitus. The client is diaphoretic, has a heart rate of 92/min, and reports palpitations. The client states, "I went for my morning run and feel exhausted." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

Exhibits The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up:

A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching?

A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?

A nurse is caring for a client who has a peripherally inserted central catheter (PICC) line in her left forearm. The client is receiving an antibiotic via intermittent IV bolus every 12 hr. Which of the following actions should the nurse take in managing the client's PICC line?

A nurse is providing discharge teaching to a client who has pulmonary tuberculosis. Which of the following findings should the nurse include as an indication the client is no longer infectious?

A nurse is caring for a client who is receiving morphine through a PCA device. Which of the following actions should the nurse take?

A nurse is providing teaching about client rights to a client who has a brain tumor. Which of the following client statements indicates an understanding of the teaching?

A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hr ago. Which of the following findings should the nurse expect?