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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale:
Prolonged sun exposure is a risk factor for osteoporosis because it can lead to vitamin D deficiency. Vitamin D is essential for calcium absorption, and low levels of vitamin D can contribute to reduced bone density and increased risk of fractures.
Choice B rationale:
Reduced intake of vitamin E is not a well-established risk factor for osteoporosis. Vitamin E is an antioxidant and plays a role in various bodily processes, but its association with osteoporosis is not supported by strong evidence.
Choice C rationale:
Drinking one glass of wine per day is not a risk factor for osteoporosis. In fact, moderate alcohol consumption has been suggested to have a protective effect on bone density in some studies.
Choice D rationale:
Exposure to second-hand tobacco smoke is a risk factor for osteoporosis. Smoking and exposure to tobacco smoke have been linked to decreased bone density and increased risk of fractures, making this an important point to include in the teaching.
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not cross the client's legs when sitting in the recliner following a total left hip arthroplasty. Crossing the legs can put strain on the operative hip and may increase the risk of dislocation or other complications.
Choice B rationale:
Providing a heating pad to the operative hip is not recommended. Heat can increase blood flow to the area and may lead to increased swelling and potential complications in the postoperative period.
Choice C rationale:
Placing a pillow between the legs when turning the client to their side is the correct action. This technique is known as the "abduction pillow”. or "wedge pillow.”. It helps maintain proper hip alignment and prevents the operated leg from crossing the midline, reducing the risk of dislocation and promoting healing.
Choice D rationale:
Having the client lean forward when assisting them out of the bed is not appropriate after a total left hip arthroplasty. Leaning forward can put strain on the hip joint and increase the risk of injury.
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