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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Petechiae indicate a risk of bleeding due to low platelet levels or dysfunction. Bleeding precautions aim to minimize the risk of injury and bleeding events.
A While knowing the blood type is generally important for medical management, it is not the immediate priority based on the presence of petechiae alone.
C. Intravenous pain medications, especially those that can affect platelet function (like NSAIDs), may increase the risk of bleeding.
D. Airborne precautions are used for diseases transmitted by airborne droplets smaller than 5 microns, such as tuberculosis or measles. Petechiae are not indicative of an airborne disease transmission risk.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}
Explanation
The client is at risk for developing bleeding due to platelet count
Rationale:
The client's platelet count at the 3-month visit is 112,000/mm3, which is below the normal range (150,000 to 400,000/mm3). Platelets are crucial for blood clotting, and a low platelet count increases the risk of bleeding.
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