A nurse on a Medical-Surgical unit is caring for an elderly patient. Which of the following nursing observations would indicate that the patient is at risk for developing a pressure ulcer?
Patient ate half of his breakfast tray.
Patient has a raised erythematous rash below the knee.
Patient has a capillary refill of less than 2 seconds.
Patient is incontinent of stool.
The Correct Answer is D
Choice A rationale:
The choice "Patient ate half of his breakfast tray" is not the correct answer. While poor appetite or decreased intake can impact a patient's nutritional status, it is not a direct indicator of pressure ulcer risk.
Choice B rationale:
The choice "Patient has a raised erythematous rash below the knee" is not the correct answer. This might indicate a localized skin issue, such as an allergic reaction or dermatitis, but it is not a clear sign of pressure ulcer risk.
Choice C rationale:
The choice "Patient has a capillary refill of less than 2 seconds" is not the correct answer. Capillary refill time assesses peripheral circulation and is useful in evaluating perfusion, but it is not specifically indicative of pressure ulcer risk.
Choice D rationale:
The correct answer is "Patient is incontinent of stool." Choice D is the correct answer. Incontinence, especially fecal incontinence, increases the risk of pressure ulcer development. Prolonged exposure to moisture from urine or stool weakens the skin's integrity, making it more susceptible to breakdown when pressure is applied over bony prominences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Sanguineous. Sanguineous drainage is typically bright red and consists of fresh blood. It indicates active bleeding from the wound. In this case, the drainage described is not bright red but rather light red-pink, suggesting that it is not purely sanguineous.
Choice B rationale:
Serous. Serous drainage is thin, watery, and typically clear or slightly yellowish in color. It is a normal part of the wound healing process and is not indicative of active bleeding. However, the drainage described in the question is light red-pink, which is not consistent with serous drainage.
Choice C rationale:
Purulent. Purulent drainage is thick, often opaque, and can range in color from yellow to green. It indicates the presence of infection in the wound. The description of watery light red-pink drainage does not align with the characteristics of purulent drainage.
Choice D rationale:
Serosanguineous. Serosanguineous drainage is a combination of serous and sanguineous fluids. It appears as a thin, watery drainage that is pink-tinged due to the presence of a small amount of blood. This description matches the observed drainage in the question. Serosanguineous drainage is common during the initial stages of wound healing and is considered a normal part of the process.
Correct Answer is D
Explanation
Choice A rationale:
The choice "Pigeon" is not the correct answer. Pigeon chest, also known as pectus carinatum, is a deformity of the chest characterized by a protrusion of the sternum and ribs. This condition is not associated with chronic bronchitis.
Choice B rationale:
The choice "Funnel" is not the correct answer. Funnel chest, or pectus excavatum, is a deformity where the sternum is sunken into the chest. It is not the expected chest shape in chronic bronchitis.
Choice C rationale:
The choice "Kyphotic" is not the correct answer. Kyphosis refers to an excessive outward curvature of the thoracic spine, leading to a rounded upper back appearance. This is not the typical chest shape seen in chronic bronchitis.
Choice D rationale:
The correct answer is "Barrel." Choice D is the correct answer. Chronic bronchitis is a type of chronic obstructive pulmonary disease (COPD) characterized by airway inflammation and narrowing. Over time, this can lead to air trapping in the lungs and an increase in the anteroposterior diameter of the chest. This results in a barrel-shaped chest appearance, where the chest appears rounded and the ribs are more horizontal. This adaptation allows for increased lung capacity to accommodate for the compromised airflow in patients with chronic bronchitis.
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