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 A
Explanation
A. Iron:
Function: Iron is essential for the formation of hemoglobin, a protein in red blood cells that carries oxygen from the lungs to the rest of the body. It is vital for oxygen transport and overall cellular function.
Relevance: Iron deficiency can lead to anemia, characterized by reduced oxygen-carrying capacity of the blood, resulting in fatigue, weakness, and other symptoms.
B. Magnesium:
Function: Magnesium is involved in various cellular processes, including muscle and nerve function, blood glucose control, and bone health.
Relevance: While magnesium has important functions in the body, it is not directly involved in the transport of oxygen like iron.
C. Phosphorus:
Function: Phosphorus is a key component of DNA, RNA, and ATP, playing a role in energy metabolism, bone health, and acid-base balance.
Relevance: While important for cellular processes, phosphorus is not specifically linked to the transport of oxygen.
D. Potassium:
Function: Potassium is crucial for maintaining proper fluid balance, nerve impulses, and muscle contractions.
Relevance: Potassium is not directly involved in the transport of oxygen; its primary functions are related to electrolyte balance and cellular activities.
Correct Answer is D
Explanation
A. Bradycardia:
Low blood sugar levels can lead to bradycardia, a slower than normal heart rate.
B. Flushed skin:
Typically, low blood sugar levels might cause pallor or cool, clammy skin, rather than flushing.x
C. Decreased appetite:
Low blood sugar might result in increased hunger or a feeling of needing to eat rather than decreased appetite.
D. Tremors:
Hypoglycemia often presents with symptoms like tremors or shakiness due to the body's response to low blood sugar.
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