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

Answer and Explanation

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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Correct Answer is B

Explanation

B. HbA1c is considered the gold standard for assessing long-term glycemic control in individuals with diabetes. It provides an overall picture of how well blood sugar levels have been controlled over the preceding 2-3 months, helping healthcare providers adjust treatment plans as needed.

A Postprandial (after-meal) blood glucose levels indicate how well blood sugar levels are controlled after eating. While important for immediate assessment of glucose management after meals, it does not provide a comprehensive view of long-term glycemic control.

C. While fasting blood glucose levels are important in daily diabetes management, they do not provide the extended timeframe assessment that HbA1c does for long-term control.

D. OGTT results are not typically used to monitor long-term glycemic control in individuals with established diabetes mellitus. It assesses how the body responds to a glucose load and is not as practical or common for routine monitoring compared to HbA1c.

A. Determine the client's blood type. B. Institute bleeding precautions. C. Avoid administering IV pain medication. D. Implement airborne precautions.

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.

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A nurse is assessing clients for skin integrity. Which of the following clients is at greatest risk for developing skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months. Which of the following laboratory results should the nurse monitor to determine long- term glycemic control?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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