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 D
Explanation
D. Naloxone competitively binds to opioid receptors, displacing opioids from these receptors and rapidly reversing their effects. It is the drug of choice for managing opioid-induced respiratory depression and is administered to restore adequate ventilation and prevent respiratory arrest.
A Diphenhydramine is an antihistamine with sedative properties. It is used primarily for allergic reactions and as a sleep aid. Diphenhydramine is not indicated for reversing respiratory depression caused by opioid overdose. It does not antagonize opioid receptors or reverse the effects of opioids.
B. Flumazenil is not effective in reversing respiratory depression caused by opioid overdose. It does not affect opioid receptors or reverse the respiratory depressant effects of opioids.
C. Calcium gluconate is a form of calcium used to treat hypocalcemia or to counteract the cardiac effects of hyperkalemia. It does not reverse opioid-induced respiratory depression. It is not indicated in this situation.
Correct Answer is D
Explanation
D. This practice is recommended to maintain catheter patency and prevent occlusion.
A Changing the transparent membrane dressing is typically done every 5 to 7 days, not daily, unless it's soiled or compromised.
B. Accessing the catheter with a non-coring needle is not applicable in this context as PICC lines are already in place and do not require such needles for access.
C. Maintaining a continuous IV infusion is not necessary for a client receiving intermittent IV bolus medication and could increase the risk of complications without providing any benefit in this scenario.
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