A nurse is caring for a 68-year-old male client who was admitted to a rehabilitation unit following a repair of a right hip fracture. The client has limited mobility and requires assistance to turn and transfer out of bed. It’s Day 4, 0700hrs.
The client is at greatest risk for developing
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
The client is at greatest risk for developing a Pressure ulcer due to Limited mobility.
The client’s limited mobility and the need for assistance to turn and transfer out of bed increases the risk of pressure ulcers. Pressure ulcers, also known as bedsores, are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin. They most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone. People most at risk of pressure ulcers are those with a medical condition that limits their ability to change positions or those who spend most of their time in a bed or chair.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Troponin is a cardiac enzyme which indicates a client has experienced a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition.
Choice B rationale
Albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time. Therefore, a nurse
should expect altered albumin levels in a client who reports anorexia and is experiencing malnutrition.
Choice C rationale
Total bilirubin is altered in clients who are experiencing hepatobiliary disease. It is not a laboratory test that supports a diagnosis of malnutrition.
Choice D rationale
Creatine kinase is a cardiac enzyme which is useful in the diagnosis of a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition.
Correct Answer is A
Explanation
Choice A rationale
A colonoscopy is the standard investigation for colorectal cancer. It allows for the visualization of the entire colon and rectum, and can also allow for the removal of polyps and the taking of biopsies if needed.
Choice B rationale
Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure used to diagnose diseases of the gallbladder, biliary system, pancreas, and liver, not rectal cancer.
Choice C rationale
An upper GI series, which involves X-rays of the esophagus, stomach, and small intestine, would not be used for screening for rectal cancer.
Choice D rationale
An upper GI endoscopy, which involves the use of a flexible endoscope to visualize the esophagus, stomach, and duodenum, would not be used for screening for rectal cancer.
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