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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
Explanation
A To obtain reliable results, it is generally recommended to collect samples from different areas of the stool across multiple bowel movements rather than from a single sample.
detecting occult blood if it is present in the stool but not evenly distributed throughout. It also helps to reduce the chance of obtaining a false negative result.
C. Urine can interfere with the accuracy of fecal occult blood testing, leading to false positive results. Therefore, any sample that contains visible urine should be discarded to prevent inaccurate test results.
B. While gloves should be worn to maintain standard precautions and prevent direct contact with feces, sterile gloves are not required for this procedure. Standard medical examination gloves are sufficient to ensure hygiene and prevent contamination during sample collection.
D. The guaiac smear should be performed on a small portion of stool obtained from different areas within the bowel movement, not specifically from the outer edge of formed stool. The goal is to sample from different parts to increase the likelihood of detecting any occult blood present.
Correct Answer is C
Explanation
C. This is crucial because good medication adherence is essential for a transplant recipient to prevent rejection and maintain overall health. Non-adherence can jeopardize the transplant's success.
A This could be a risk factor for the client's own health, but it's not directly related to the transplant process or medication adherence.
B. This highlights a psychosocial concern, important for overall well-being, but doesn't directly impact the transplant candidacy.
D. This might be relevant for the medical history, but it doesn't directly affect medication adherence or the immediate transplant candidacy (unless the asthma is severe and uncontrolled).
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