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. Providing the client with a trapeze bar allows them to move and reposition in bed independently without compromising the traction on the affected leg.
A Checking pressure points every 2 hours is generally recommended for clients at risk of developing pressure ulcers, but it's not specific to skeletal traction care.
C. Removing the weights prematurely can lead to loss of traction and compromise the therapeutic benefit of the traction.
D. When a client has skeletal traction, they should avoid using the affected limb for any weight-bearing activities or for repositioning
Correct Answer is A
Explanation
A Diphenhydramine is an antihistamine, which helps reduce allergic reactions like hives and urticaria.
B. Spironolactone is a diuretic and potassium-sparing aldosterone antagonist, primarily used for managing high blood pressure and fluid retention. It's not typically used for allergic reactions.
C. Desmopressin helps control bleeding and is not suitable for allergic reactions.
D. Metoclopramide helps with nausea and vomiting and wouldn't be the first choice for hives and urticaria.
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