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)
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Proteinuria is a hallmark finding in nephrotic syndrome. Proteinuria refers to the presence of excess protein, particularly albumin, in the urine. It occurs due to increased permeability of the glomerular filtration barrier, allowing proteins to leak into the urine rather than being retained in the bloodstream.
A. Individuals with nephrotic syndrome may be at an increased risk of thrombosis (formation of blood clots) due to loss of anticoagulant proteins such as antithrombin III in the urine.
C. Nephrotic syndrome is characterized by hypoalbuminemia, which is a decreased level of albumin in the bloodstream. The loss of albumin in the urine leads to decreased serum albumin levels, contributing to edema formation and other complications associated with nephrotic syndrome.
D. Decreased serum lipid levels is not a typical finding in nephrotic syndrome. In fact, individuals with nephrotic syndrome often have dyslipidemia, characterized by elevated serum lipid levels, including cholesterol and triglycerides.
Correct Answer is D
Explanation
D. A thrill is a palpable vibration or buzzing sensation felt over the graft site, caused by turbulent blood flow. In the context of an arteriovenous graft, a palpable thrill is typically considered a positive finding, indicating adequate circulation through the graft. It suggests that blood is flowing smoothly from the arterial to the venous side of the graft.
A. The presence of a bruit is typically considered a positive finding, indicating adequate blood flow through the graft. Therefore, the absence of a bruit may indicate inadequate circulation or a potential complication such as graft occlusion or stenosis.
B. Normal blood pressure is not a specific indicator of the adequacy of circulation through an arteriovenous graft.
C. A dilated appearance of the graft may suggest venous hypertension or increased pressure within the graft. While this could indicate adequate blood flow, it may also suggest problems such as venous stenosis or thrombosis, which can impede circulation through the graft.
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