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

Answer and Explanation

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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Correct Answer is D

Explanation

A. "My appetite will be decreased."
Explanation: Hyperglycemia is often associated with increased appetite rather than decreased appetite.

B. "I might experience blurry vision at times."
Explanation: This is correct. Blurry vision can be a symptom of hyperglycemia due to changes in the fluid levels in the eye caused by high blood sugar.

C. "My breath may have a fruity odor."
Explanation: Fruity breath odor is associated with diabetic ketoacidosis (DKA), which is a severe complication of diabetes. It occurs due to the production of ketones during uncontrolled diabetes, leading to this distinct odor. While it's related to high blood sugar, it's more specifically linked to DKA.

D. "I will be more thirsty than usual."
Explanation: Increased thirst is a classic symptom of hyperglycemia. When blood sugar levels are high, the body tries to flush out the excess sugar through increased urination, leading to dehydration and subsequently increased thirst.

A. "Sweating can occur with hypoglycemia." B. "My son might complain of feeling shaky when he has a low blood glucose level." C. "My son might have nausea and vomiting with hypoglycemia." D. "The onset of low blood glucose usually occurs rapidly."

Correct Answer is D

Explanation

A. "Sweating can occur with hypoglycemia."
Explanation: This statement is correct. Sweating is one of the common symptoms of hypoglycemia. When blood glucose levels drop too low, the body releases stress hormones, including adrenaline, which can lead to sweating.

B. "My son might complain of feeling shaky when he has a low blood glucose level."
Explanation: This statement is correct. Shaking or feeling shaky is a common symptom of hypoglycemia. It results from the release of stress hormones in response to low blood glucose.

C. "My son might have nausea and vomiting with hypoglycemia."
Explanation: This statement is correct. Nausea and vomiting can be symptoms of hypoglycemia. While not everyone with low blood glucose will experience these symptoms, they are possible manifestations.

D. "The onset of low blood glucose usually occurs rapidly."
Explanation: This statement is generally true, but it can vary. The onset of hypoglycemia can happen rapidly, especially if the individual has taken a fast-acting insulin or medication. However, the speed of onset can depend on various factors, and it's important to emphasize that it may not always be immediate.

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A nurse is collecting data on a client. Which of the following findings increase the client's risk of a pressure injury?

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