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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?

A.

BMI of 20

B.

Peripheral neuropathy

C.

Immobility

D.

Hypoperfusion

E.

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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Related Questions

Correct Answer is C

Explanation

A. High-fiber cereals:
High-fiber cereals may not be suitable for a soft diet, as they can be challenging to chew and may not meet the texture requirements of a soft diet.

B. Raw vegetables:
Raw vegetables are generally not recommended for a soft diet, as they can be difficult to chew and digest. Cooking or steaming vegetables can make them softer and more suitable for a soft diet.

C. Ground beef:
This is the correct answer. Ground beef can be included in a soft diet, especially if it is cooked to a tender consistency. It provides a good source of protein while meeting the requirements of a soft-textured diet.

D. Fruit with the skin:
Fruits with skins may pose a challenge for individuals on a soft diet, as the skin can be difficult to chew and swallow. Choosing peeled or canned fruits without skins may be more appropriate.

Correct Answer is C

Explanation

A. Explain alternatives to the procedure to the client.
The nurse should provide information about alternative treatments or procedures available to the client, ensuring they have a comprehensive understanding of their options.

B. Discuss the risks of the procedure with the client.
It is crucial for the nurse to communicate the potential risks and complications associated with the procedure to the client, allowing them to make an informed decision.

C. Confirm that the client is competent to sign for the procedure.
Before obtaining informed consent, the nurse should ensure that the client has the mental capacity to understand the information provided, make decisions, and provide consent.

D. Inform the client about what will occur during the procedure.
The nurse should educate the client about the details of the procedure, including what to expect before, during, and after. This information aids in the client's understanding and decision-making process.

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