A nurse is caring for a group of clients.
Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?
A client who is unresponsive to verbal commands and changes position occasionally.
A client who is alert and responsive and eats 25% of each meal.
A client who is receiving enteral feeding and can change position independently.
A client who makes frequent slight changes in position and walks occasionally.
The Correct Answer is A
Choice A rationale:
The client who is unresponsive to verbal commands and changes position occasionally is at the highest risk for developing a pressure injury. Pressure injuries, also known as pressure ulcers or bedsores, are more likely to occur in clients who cannot independently reposition themselves. Unresponsive clients are unable to sense discomfort and adjust their positions, which makes them particularly vulnerable to pressure injuries. Changing position occasionally may not be sufficient to prevent these injuries in such clients. Pressure injuries are a result of prolonged pressure on a particular area, causing damage to the skin and underlying tissues due to reduced blood flow. Clients who are unresponsive need more vigilant monitoring and frequent repositioning to prevent pressure injuries.
Choice B rationale:
The client who is alert and responsive and eats 25% of each meal is not at the highest risk for developing a pressure injury. While this client may have some nutritional concerns, the primary risk factor for pressure injuries is immobility or the inability to change position independently. The ability to eat some of each meal indicates at least some level of mobility and participation in activities of daily living, which can help reduce the risk of pressure injuries.
Choice C rationale:
The client who is receiving enteral feeding and can change position independently is not at the highest risk for developing a pressure injury. Enteral feeding provides adequate nutrition, and the ability to change position independently reduces the risk of pressure injuries. Changing positions helps distribute pressure and prevents localized areas of prolonged pressure that can lead to tissue damage.
Choice D rationale:
The client who makes frequent slight changes in position and walks occasionally is also not at the highest risk for developing a pressure injury. Walking and frequent position changes help in preventing pressure injuries. The risk is lower for clients who can independently make slight changes in position and engage in ambulation. These activities promote blood flow and relieve pressure on specific areas of the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Peripheral vascular disease does not directly place the client at a higher risk for an incisional hematoma. While it is a vascular condition, the use of anticoagulant medications is a more significant risk factor for bleeding complications.
Choice B rationale:
Urinary incontinence is not directly related to an increased risk of incisional hematoma. Incontinence is a separate issue and does not influence surgical outcomes in the context of hematoma formation.
Choice C rationale:
Taking anticoagulant medications is a significant risk factor for incisional hematoma. Anticoagulants reduce the blood's ability to clot, which can lead to excessive bleeding at the surgical site and the formation of hematomas.
Choice D rationale:
Being underweight is not a primary risk factor for incisional hematoma. While poor nutrition and overall health can influence wound healing, anticoagulant use is a more direct concern for hematoma formation in surgical patients.
Correct Answer is B
Explanation
Choice A rationale:
Trust vs. Mistrust is the first stage of Erikson's theory of psychosocial development and typically occurs in infancy. It is characterized by the child's development of trust or mistrust based on the caregiver's reliability and care. This stage is not relevant to an adolescent who is rebelling against caregivers and spending more time with friends.
Choice B rationale:
Identity vs. Role Confusion is the stage of Erikson's theory that corresponds to adolescence. During this stage, adolescents seek to establish a sense of identity and may experiment with different roles and behaviors. They often question who they are and what they want to become. Rebelling against caregivers and seeking independence are common characteristics of this stage.
Choice C rationale:
Integrity vs. Despair is the final stage of Erikson's theory and occurs in late adulthood. It involves reflecting on one's life and coming to terms with the choices made. It is not relevant to the situation of an adolescent client.
Choice D rationale:
Autonomy vs. Shame and Doubt is the stage that typically occurs in early childhood, where children are developing a sense of independence and autonomy. This stage is not relevant to the adolescent client's experience of rebellion and seeking autonomy.
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