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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Free Nursing Study Resources

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.

A. Emesis of 250 mL B. Increased respiratory rate to 26/min C. Decreased anxiety D. Decreased urinary output

Correct Answer is C

Explanation

C. Morphine is a central nervous system depressant that can help decrease anxiety and relieve dyspnea in clients with acute heart failure. Therefore, a decrease in anxiety would indicate that the medication has been effective in achieving its intended outcome.
A. Emesis, or vomiting, is not an expected outcome of morphine administration in the context of acute heart failure.
B. While morphine can help alleviate dyspnea, an increased respiratory rate may indicate respiratory distress rather than effective symptom relief.
D. Morphine does not directly affect urinary output, and a decrease in urinary output may indicate other issues such as renal dysfunction or fluid overload.

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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 reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

Correct Answer is C

Explanation

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