A nurse is collecting data on a client. Which of the following findings increase the client's risk of a pressure injury?
BMI of 20
Peripheral neuropathy
Immobility
Hypoperfusion
Prealbumin level of 16 mg/dL
Correct Answer : B,C,D,E
A. BMI of 20:
A BMI of 20 is within the normal range. While extremes of BMI, either low or high, can contribute to health issues, a BMI of 20 alone may not significantly increase the risk of pressure injuries.
B. Peripheral neuropathy:
Peripheral neuropathy, which involves damage to the nerves in the extremities, can lead to decreased sensation and awareness. Clients with peripheral neuropathy may have difficulty sensing pressure, friction, or discomfort, making them more susceptible to pressure injuries.
C. Immobility:
Immobility is a significant risk factor for pressure injuries. Clients who are unable to change positions frequently are more likely to develop pressure points, particularly over bony prominences. Regular repositioning is essential to prevent pressure injuries in immobile individuals.
D. Hypoperfusion:
Hypoperfusion, or inadequate blood flow to tissues, can compromise tissue viability. Proper blood circulation is crucial for delivering oxygen and nutrients to the skin and underlying tissues. Impaired perfusion can contribute to tissue damage and increase the risk of pressure injuries.
E. Prealbumin level of 16 mg/dL:
Prealbumin is a marker of nutritional status. A low prealbumin level (16 mg/dL) indicates malnutrition, which can impair the body's ability to repair and maintain tissues, including the skin. Malnourished individuals are at an increased risk of developing pressure injuries.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Diminished reflexes:
Explanation: Diminished reflexes are not typically associated with hypoglycemia. Instead, hypoglycemia may cause hyperactive reflexes or tremors.
B. Rapid respirations:
Explanation: Rapid respirations are not a common manifestation of hypoglycemia. In hypoglycemia, the body might respond with shallow, rapid breathing or hyperventilation.
C. Acetone breath:
Explanation: Acetone breath, often described as fruity or sweet, is associated with diabetic ketoacidosis (DKA), which is a complication of hyperglycemia rather than hypoglycemia.
D. Headache:
Explanation: Headache is a common manifestation of hypoglycemia. It can occur as a result of decreased glucose levels affecting the brain.
Correct Answer is D
Explanation
A. Crackles throughout both lung fields:
Crackles in the lung fields could indicate fluid overload, which is a concern. However, in the context of treating hyponatremia with hypertonic saline, it might not be an immediate adverse effect related to the saline infusion itself.
B. Radial pulse of 105 beats/min:
An increase in heart rate can be associated with hypertonic saline infusion. It might be expected due to the osmotic effects of the saline.
C. Sediment and blood in the urine:
Sediment and blood in the urine could be indicative of kidney damage or injury. This is not a typical side effect of hypertonic saline infusion for hyponatremia.
D. Blood pressure increases from 88/50 to 122/74 mmHg:
A significant increase in blood pressure can be an adverse effect of hypertonic saline. Rapid correction of hyponatremia can lead to osmotic demyelination syndrome, which can manifest with neurological symptoms and changes in blood pressure.
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