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 D
Explanation
A. Report of decreased urinary output
Explanation: Decreased urinary output is not typically associated with hyperglycemia. In fact, increased urinary output (polyuria) is more characteristic.
B. Random blood glucose 126 mg/dL
Explanation: This level is within the normal range for random blood glucose. Hyperglycemia is usually defined by higher blood glucose levels.
C. Clammy skin
Explanation: Clammy skin is not a direct manifestation of hyperglycemia. Symptoms of hyperglycemia may include increased thirst, frequent urination, and blurred vision.
D. History of poor wound healing
Explanation: This is correct. Hyperglycemia can contribute to impaired wound healing, as it affects the body's ability to repair tissues.
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.
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