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 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.
Correct Answer is B
Explanation
B. Desmopressin is a synthetic analog of vasopressin (antidiuretic hormone) that promotes water reabsorption in the kidneys, reducing urine production. It is used to treat conditions associated with excessive urination, such as diabetes insipidus or nocturnal enuresis. Since the client is experiencing excessive thirst and polyuria (excessive urine output), desmopressin would be appropriate to help reduce urine volume and manage fluid balance.
A Given the client's already high urine output, administering furosemide would further increase urine production, potentially exacerbating fluid loss and dehydration.
C. Epinephrine does not address the underlying issue of excessive thirst and polyuria related to brain injury and would not be used in this context.
D. Nitroprusside is a vasodilator that reduces blood pressure by relaxing smooth muscle in blood vessels. It is used to treat hypertensive emergencies. Nitroprusside is not relevant for addressing excessive thirst and polyuria due to brain injury.
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