A nurse is caring for a female client who had a stroke. Which of the following findings should indicate to the nurse that the client has an increased risk of developing skin breakdown?

Hgb 18 g/dL (12 to 16 g/dl)

WBC 12.000/mm3 (5,000 to 10,000/mm3)

25-Hydroxyvitamin D 92 ng/ml. (25 to 80 ng/mL)

Albumin 3.1 g/dL (3.5 to 5 g/dL)

Answer and Explanation

The Correct Answer is D

Albumin is a protein that plays a crucial role in maintaining skin health. Low albumin levels (hypoalbuminemia) can lead to poor wound healing and skin vulnerability.

Hemoglobin level, white cell count and 25-hydroxyvitamin have no direct role in skin breakdown.

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Correct Answer is C

Explanation

Kale is high in vitamin K, which can antagonize the effects of warfarin. Warfarin works by inhibiting vitamin K-dependent clotting factors, so consuming large amounts of vitamin K-rich foods like kale can reduce the anticoagulant effect of warfarin, leading to a decrease in the INR.

Orange juice, beef stew and yogurt have no interactions with warfarin.

A. "I will ensure their neck is flexed backwards when they're lying on their stomach." B. "I will support their feet with a rolled pillow when they are lying on their back." C. "I will rest their heels on the mattress when they are sitting up in bed." D. "I will use a thick pillow under their head to support the neck."

Correct Answer is B

Explanation

B. Supporting the feet with a rolled pillow helps prevent foot drop (a common issue in hemiplegia). It maintains the ankle in a neutral position, preventing contractures.
A. When lying on the stomach (prone position), the neck should be neutral (neither flexed nor extended). Flexing the neck backward can strain the cervical spine and compromise airway alignment.
C. For a client with right-sided hemiplegia, the affected leg (right leg) should be supported to prevent foot drop.
D. A thick pillow under the head can cause neck hyperextension.
The head should be supported with a small, firm pillow to maintain a neutral neck position.

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A nurse is caring for a female client who had a stroke. Which of the following findings should indicate to the nurse that the client has an increased risk of developing skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a new prescription for warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following foods interacts with this medication?

Correct Answer is C

Explanation

A nurse is teaching about safe positioning with the caregiver of a client who has right-sided hemiplegia following a stroke. Which of the following statements by the caregiver indicates an understanding of the teaching?

Correct Answer is B

Explanation

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