A nurse is providing care for four clients on a medical-surgical unit, Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)
A client who has protein calorie malnutrition
A client who has type1 diabetes mellitus and is hyperglycemic
A client who has right-sided heart failure and 4+ edema to the lower extremities
A client who has postoperative delirium
A client who is ambulatory following a cardiac catheterization 4 hr ago
Correct Answer : A
A. Protein-calorie malnutrition can lead to decreased tissue integrity and delayed wound healing, increasing the risk of pressure ulcer development due to compromised nutritional status.
B. Diabetes, especially when uncontrolled, can lead to poor circulation and neuropathy, which increases the risk of pressure ulcers. Hyperglycemia can also impair wound healing and compromise the immune response, further contributing to the risk.
C. Edema increases pressure on the skin and underlying tissues, impairing circulation and increasing the risk of pressure ulcers, especially in areas where there is constant pressure or friction against surfaces.
D. A client with postoperative delirium is not necessarily at risk of delirium.
E. A client post cardiac catheterization and already ambulating is not at risk of pressure sores
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Quadriceps setting exercises help strengthen the quadriceps muscles, which play a crucial role in knee stability and function. These exercises can be initiated early in the postoperative period and are typically part of the rehabilitation program following a partial meniscectomy.
A. Full weight bearing may place excessive stress on the knee joint and hinder the healing process.
B. Heat therapy is generally not recommended immediately after a partial meniscectomy. Heat can increase blood flow and swelling, which may exacerbate pain and inflammation in the early postoperative period.
C. Range of motion (ROM) exercises help prevent stiffness and promote flexibility in the knee joint after surgery. However, these exercises should not be initiated immediately.
Correct Answer is B
Explanation
B. Phalen's sign is a test for carpal tunnel syndrome. It is positive when the client experiences numbness, tingling, or pain in the median nerve distribution (especially the thumb, index finger, middle finger, and half of the ring finger) within 1 minute of wrist flexion.
A. Cool extremities are not typically associated with carpal tunnel syndrome. They may indicate issues related to circulation rather than compression of the median nerve.
C. Trousseau's sign is a test for latent tetany, which is associated with hypocalcemia. It involves inflating a blood pressure cuff on the upper arm and observing for carpal spasm. It is not a manifestation of carpal tunnel syndrome.
D. A decreased radial pulse may indicate vascular issues or compression of the radial artery, not carpal tunnel syndrome.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.