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 {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}

Explanation

Urine ketones:

They are commonly present in DKA due to the breakdown of fats as an alternative energy source when insulin is insufficient. Ketones in urine are a hallmark sign of DKA.

Ketones may not be present in urine in HHS because insulin levels are sufficient to prevent excessive breakdown of fats. Therefore, urine ketones are more specific to DKA.

Creatinine greater than expected reference range

DKA: In DKA, dehydration and electrolyte imbalances can lead to acute kidney injury (AKI), resulting in elevated creatinine levels.

HHS: Elevated creatinine can also occur in HHS due to severe dehydration and reduced kidney perfusion.

Blood glucose greater than expected reference range:

DKA: Extremely high blood glucose levels (typically >250 mg/dL) are a hallmark of DKA due to insulin deficiency and the resultant inability to transport glucose into cells for energy.

HHS: Similar to DKA, HHS is characterized by extremely high blood glucose levels (often >600 mg/dL). Therefore, elevated blood glucose levels are consistent with both DKA and HHS.

Skin turgor

DKA: Decreased skin turgor is indicative of dehydration, which is common in DKA due to excessive urination (polyuria) and fluid loss.

HHS: Similarly, decreased skin turgor can also be seen in HHS due to profound dehydration caused by excessive hyperglycemia and osmotic diuresis.

Blood pH greater than expected reference range

DKA: DKA is characterized by metabolic acidosis, leading to a decreased blood pH (<7.35). Therefore, a pH greater than expected reference range would not be typical for DKA.

HHS: HHS, on the other hand, is characterized by severe hyperglycemia without significant ketoacidosis. Patients with HHS can have a normal or even elevated blood pH (>7.45) due to compensation mechanisms and absence of significant acidosis.

A. "Your provider wouldn't prescribe this medication if it weren't necessary." B. "Most clients feel better after taking the antibiotic." C. "If you don't take this medication, you will feel worse." D. "I will tell your provider that you do not want to take this medication."

Correct Answer is D

Explanation

A While this statement is factual, it may come off as dismissive of the client’s concerns. The client may feel that their feelings and autonomy are not being respected. It's important to provide education but also to engage the client in a conversation about their concerns.

B. While this statement is intended to provide reassurance and encouragement, it may not be accurate for all clients or situations. It could also oversimplify the client's concerns and may not address the specific reasons for their reluctance to take the medication.

C. This response emphasizes the potential consequences of not adhering to the prescribed treatment plan. It highlights the importance of the medication in managing or treating the client's condition effectively. However, it may come across as threatening or coercive, which is not conducive to building a trusting and collaborative relationship with the client.

D. This is an appropriate response as it acknowledges the client’s autonomy and concern. It indicates that the nurse respects the client’s wishes and that the client will have the opportunity to discuss their concerns further with the provider. This fosters open communication and may lead to a better understanding of the necessity of the medication.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}

Explanation

A nurse is caring for a client who has been prescribed an antibiotic. The client tells the nurse, "I don't like taking medications because I don't think I need them." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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