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 D
Explanation
D. NPO status is typically implemented in the initial management of acute pancreatitis to rest the pancreas and reduce pancreatic enzyme secretion, which can exacerbate inflammation and tissue damage. Nutritional support may be gradually reintroduced once the client's condition stabilizes and symptoms improve.
A. Placing the client in a supine position is not recommended for acute pancreatitis because it can exacerbate pain and discomfort.
B. The priority in acute pancreatitis is to address pain, manage complications such as fluid imbalances or infections, and support pancreatic rest.
C. Hypercalcemia can occur as a complication of acute pancreatitis due to calcium mobilization from damaged pancreatic cells. However, keeping the client NPO is priority.
Correct Answer is C
Explanation
C. Oliguria can occur in severe cases of left-sided heart failure. When the heart's ability to pump blood forward is compromised, blood flow to the kidneys decreases, leading to decreased urine production.
A. Pedal edema is more commonly associated with right-sided heart failure.
B. Neck vein distention is typically associated with right-sided heart failure where increased pressure in the right side of the heart leads to jugular venous distention
D. Enlarged liver, or hepatomegaly, can occur in right-sided heart failure due to congestion and backup of blood in the hepatic circulation.
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