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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Dry mucous membranes:
Explanation: Dry mucous membranes are not typically associated with hypoglycemia. Instead, they might be seen in conditions such as dehydration.
B. Fruity breath odor:
Explanation: Fruity breath odor is more commonly associated with diabetic ketoacidosis (DKA), which is a complication of hyperglycemia, not hypoglycemia.
C. Diaphoresis:
Explanation: Diaphoresis, or excessive sweating, is a common manifestation of hypoglycemia. It results from the activation of the sympathetic nervous system in response to low blood sugar levels.
D. Polyuria:
Explanation: Polyuria, or increased urination, is not a typical manifestation of hypoglycemia. It is more commonly associated with hyperglycemia and diabetes.
Correct Answer is C
Explanation
A. Hypertension:
Hypovolemia is characterized by a decrease in blood volume. This reduction in blood volume usually leads to decreased blood pressure, not hypertension.
B. Peripheral edema:
Edema is more commonly associated with hypervolemia (excess fluid volume) rather than hypovolemia. In hypovolemia, the body is experiencing a deficit of fluids, and edema is not a typical manifestation.
C. Oliguria:
This is the correct answer. Oliguria, or reduced urine output, is a common finding in hypovolemia. When the body is low on fluids, the kidneys try to conserve water by decreasing urine production.
D. Bradycardia:
Hypovolemia often leads to tachycardia (an increased heart rate) as the body attempts to compensate for the decreased blood volume by pumping the existing blood more quickly. Bradycardia is not a typical finding in hypovolemia.
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