A nurse is caring for several clients who are at risk of developing a pressure injury. Which of the following clients is most at risk?

A 23-year-old client who is in skeletal traction.

A 67-year-old client who has coronary artery disease.

A 32-year-old client who has a spinal cord injury.

A 55-year-old client who has emphysema.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A 23-year-old client in skeletal traction may be at risk of pressure injuries, but being young and presumably healthier than the other options, this client may have a lower risk compared to the other choices.

Choice B rationale:

A 67-year-old client with coronary artery disease may be at risk of pressure injuries, especially if the client has limited mobility or is bedridden. However, coronary artery disease alone does not significantly increase the risk of pressure injuries.

Choice C rationale:

A 32-year-old client with a spinal cord injury is most at risk of developing a pressure injury. Spinal cord injuries often result in paralysis or limited mobility, leading to prolonged pressure on specific areas of the body, which can cause pressure ulcers.

Choice D rationale:

A 55-year-old client with emphysema may have compromised lung function, but this alone does not significantly increase the risk of pressure injuries. Pressure injuries are primarily related to immobility and pressure on specific body areas.

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Correct Answer is D

Explanation

Choice A rationale:

Severe headache can be a symptom of a subdural hematoma, but it is not the earliest manifestation of a change in neurological status. Other symptoms may appear before a severe headache, such as an altered level of consciousness.

Choice B rationale:

Bradycardia can occur with a subdural hematoma, especially as intracranial pressure increases. However, it is not the earliest manifestation of a change in neurological status. Changes in heart rate may occur later in the progression of the condition.

Choice C rationale:

Widened pulse pressure can also occur in patients with a subdural hematoma due to increased intracranial pressure. However, it is not the earliest manifestation of a change in neurological status. Other neurological signs would likely appear before changes in pulse pressure are evident.

Choice D rationale:

Change in level of consciousness is the earliest manifestation of a change in neurological status with a subdural hematoma. As intracranial pressure increases, the brain's functioning can be affected, leading to alterations in consciousness, ranging from mild confusion to unconsciousness.

A. Maintain the client in a semi-Fowler's position. B. Administer an enema 1 hr prior to surgery. C. Apply a warm pack to the client's lower abdomen. D. Place the client on a clear liquid diet.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should maintain the client in a semi-Fowler's position to promote comfort and reduce the risk of complications related to appendicitis. This position helps to decrease pressure on the abdomen and may alleviate pain by reducing tension on the abdominal muscles.
Choice B rationale:
Administering an enema 1 hour prior to surgery is not indicated for a client with appendicitis. Enemas are generally not recommended for clients with suspected or confirmed appendicitis as they can potentially worsen inflammation and cause perforation of the inflamed appendix.
Choice C rationale:
Applying a warm pack to the client's lower abdomen is contraindicated in appendicitis. Heat can exacerbate inflammation and should be avoided in such cases.
Choice D rationale:

Placing the client on a clear liquid diet is not appropriate for appendicitis. Clients with appendicitis are typically NPO (nothing by mouth) to avoid stimulating the gastrointestinal tract and reduce the risk of rupture if surgery is needed.

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A nurse is caring for several clients who are at risk of developing a pressure injury. Which of the following clients is most at risk?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is providing care for a client who has a subdural hematoma. The nurse should identify that which of the following is the earliest manifestation of a change in neurological status?

Correct Answer is D

Explanation

A nurse in an emergency department is caring for a client who has appendicitis. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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