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 B
Explanation
Choice A rationale:
Reduced respiratory rate is not a typical manifestation of pain. In fact, pain often leads to an increased respiratory rate as the body responds to discomfort by trying to minimize it.
Choice B rationale:
Elevated blood pressure is a common manifestation of pain. When a person experiences pain, their sympathetic nervous system is activated, leading to an increase in heart rate and blood pressure. This response is designed to prepare the body to fight or flee from a potential threat, and it helps redirect blood flow to vital organs.
Choice C rationale:
Constricted pupils are not a direct manifestation of pain. In contrast, dilated pupils can be seen in response to pain as a result of sympathetic nervous system activation.
Choice D rationale:
Decreased heart rate is not typically associated with pain. Pain tends to increase heart rate as a part of the body's stress response.
Correct Answer is B
Explanation
Choice A rationale:
"Role performance overload" is not a direct adverse effect of a negative body image. Role performance overload refers to excessive demands and responsibilities in one's life, which can lead to stress and burnout. While a negative body image can contribute to stress, it does not directly cause role performance overload.
Choice B rationale:
"Development of an eating disorder" is a well-documented adverse effect of a negative body image. Individuals with a negative body image may develop eating disorders like anorexia nervosa or bulimia as they strive for an idealized body image. This choice is directly related to the topic of negative body image.
Choice C rationale:
"Mistrust" is not a typical adverse effect of a negative body image. Mistrust is more related to issues of trust and interpersonal relationships, while a negative body image primarily affects one's self-perception.
Choice D rationale:
"Self-absorption" can be a consequence of a negative body image, as individuals may become preoccupied with their appearance and self-worth based on their body. However, the most direct and severe consequence is the development of eating disorders, as mentioned in choice B. .
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