A nurse is performing a pressure injury risk assessment for a client. Which of the following findings increases the client's risk of a pressure injury?

BMI of 20

Peripheral neuropathy

Immobility

Hypoperfusion

Answer and Explanation

Correct Answer : B,C,D

A. BMI of 20: While a BMI of 20 is on the lower end of the normal range, it does not necessarily indicate a high risk for pressure injuries. Extreme low BMI may pose a risk, but a BMI of 20 alone is not a definitive factor in increasing pressure injury risk compared to the other listed conditions.
B. Peripheral neuropathy: Peripheral neuropathy impairs sensation in the skin, which reduces the client’s ability to feel pressure, pain, or discomfort. This diminished sensory perception increases the risk of developing pressure injuries as the client might not be aware of or respond to pressure-related issues.
C. Immobility: Immobility, or limited mobility, significantly raises the risk of pressure injuries because it prevents the client from frequently changing positions. Prolonged pressure on specific body areas can impede blood flow and lead to skin breakdown.
D. Hypoperfusion: Hypoperfusion indicates reduced blood flow to tissues, which can contribute to tissue ischemia and increase the risk of pressure injuries. Inadequate blood flow prevents adequate oxygen and nutrient delivery to the skin, making it more susceptible to damage.

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Correct Answer is A

Explanation

A) Monthly: Performing testicular self-examination (TSE) monthly is recommended to help men become familiar with the normal size and feel of their testicles. Regular self-examinations increase the likelihood of detecting any abnormalities early, which is crucial for effective treatment if testicular cancer or other issues are detected.
B) Quarterly: Quarterly self-examination is less frequent than recommended. Monthly self-examination provides a more consistent and routine approach to checking for any changes in the testicles, which is essential for early detection of potential issues.
C) Bimonthly: Bimonthly self-examination would be less frequent than recommended. Monthly self-examination is considered more effective in maintaining awareness of changes in testicular health and detecting any abnormalities early.
D) Weekly: Weekly self-examination is more frequent than necessary. Monthly examination is sufficient to familiarize oneself with the normal state of the testicles and to notice any unusual changes that may require further investigation.

A. Lordosis B. Kyphosis C. Keratosis D. Scoliosis

Correct Answer is A

Explanation

A) Lordosis: Lordosis refers to an increased inward curvature of the lumbar spine. During pregnancy, this curvature often increases to help compensate for the growing uterus and shift the center of gravity. This adjustment helps maintain balance and alignment but can lead to noticeable changes in posture.
B) Kyphosis: Kyphosis is characterized by an exaggerated outward curvature of the thoracic spine, resulting in a hunchback appearance. It is not related to the increased lumbar curvature seen during pregnancy.
C) Keratosis: Keratosis refers to a condition involving thickening or hardening of the skin, such as actinic keratosis. It is unrelated to spinal curvature or changes associated with pregnancy.
D) Scoliosis: Scoliosis is a condition marked by an abnormal lateral curvature of the spine. It does not specifically relate to the increased lumbar curvature that occurs during pregnancy due to the enlarging uterus.

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A nurse is performing a pressure injury risk assessment for a client. Which of the following findings increases the client's risk of a pressure injury?

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