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 C

Explanation

C. Lowering the bed height reduces the risk of injury in case the client falls out of bed. It also facilitates easier transfers for clients with mobility issues.

A Individuals with dementia may experience disorientation and confusion, especially in unfamiliar or dark environments. Turning off all lights can increase the risk of falls and accidents.

B. Clients with dementia may have difficulty recognizing the need to toilet or may forget where the bathroom is located. They may also have urinary or fecal incontinence. Scheduled toileting helps prevent accidents and promotes continence.

D. Sedatives or hypnotic medications can increase confusion, risk of falls, and adverse effects in older adults with dementia. They are generally not recommended as first-line treatment for sleep disturbances in dementia.

A. Remind the client of the importance of medication adherence. B. Tell the client to avoid places where there are large crowds of people. C. Initiate a referral for the client to a home health agency. D. Instruct the client to avoid eating raw vegetables.

Correct Answer is C

Explanation

C. This action demonstrates advocacy by ensuring the client has access to necessary support services that can help them maintain independence and receive adequate care in their home environment.

A Reminding the client about medication adherence is important for the client's health management, but they do not directly advocate for the client's autonomy and support system.

B. While this advice is prudent for reducing infection risk, it may limit the client's social interactions and independence. Advocacy involves balancing health promotion with the client's autonomy and quality of life.

D. Raw vegetables may carry a risk of foodborne infections, which can be more severe for individuals with compromised immune systems, such as those with AIDS.

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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

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