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 D
Explanation
The correct answer is d. "Seeing spots is a manifestation of diabetic retinopathy."
Choice A rationale:
- Clouding of the lens is not a manifestation of diabetic retinopathy.It is a characteristic of cataracts,a condition that involves a different eye structure and has a different etiology.
- Diabetic retinopathy specifically affects the retina,which is the light-sensitive tissue lining the back of the eye.It does not directly involve the lens.
- It's crucial to clarify this distinction for the client to ensure accurate understanding of their condition and potential symptoms.
Choice B rationale:
- Increased intraocular pressure is not the cause of diabetic retinopathy.It is the primary feature of glaucoma,another eye condition with distinct causes and consequences.
- Diabetic retinopathy is primarily driven by damage to the blood vessels in the retina due to prolonged high blood sugar levels.
- Explaining this difference to the client can help prevent confusion and promote appropriate preventive measures.
Choice C rationale:
- While regular eye exams are essential for early detection and management of diabetic retinopathy,the recommended frequency is more often than every 2 years.
- The American Diabetes Association recommends that individuals with diabetes have a comprehensive dilated eye exam at least annually.
- More frequent exams may be necessary depending on the individual's risk factors and the severity of their diabetes.
Choice D rationale:
- Seeing spots is a common and significant symptom of diabetic retinopathy.It occurs when blood vessels in the retina leak fluid or bleed,causing disruptions in vision.
- Other potential symptoms of diabetic retinopathy include:
- Blurred vision
- Floaters (dark specks or strings that move across the visual field)
- Difficulty seeing at night or in low light
- Loss of central vision
- Distortion of colors
- Blind spots
Correct Answer is B
Explanation
Choice A rationale:
Full-thickness skin loss with visible adipose tissue is not indicative of a stage 1 pressure injury. A stage 1 pressure injury involves intact skin with localized erythema. Full-thickness skin loss with visible adipose tissue is more characteristic of a stage 2 or higher pressure injury.
Choice B rationale:
Intact skin with localized erythema is the hallmark of a stage 1 pressure injury. In this stage, the skin is still intact, but there is non-blanchable erythema (redness) that indicates tissue damage. There is no full-thickness skin loss, and the underlying structures are not visible.
Choice C rationale:
Full-thickness skin loss with visible bone is not characteristic of a stage 1 pressure injury. This description is more in line with a stage 4 pressure injury, where there is extensive tissue loss, and bone or other underlying structures are visible.
Choice D rationale:
Partial-thickness skin loss with red tissue in the wound bed is not indicative of a stage 1 pressure injury. This description is more typical of a stage 2 pressure injury, where there is partial-thickness skin loss, but the wound bed may contain pink or red tissue without visible adipose tissue.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.