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 C
Explanation
Choice A rationale:
Cyanosis - Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. This is an objective sign that can be visually assessed, not based on the patient's description.
Choice B rationale:
Petechiae - Petechiae are small, pinpoint, red or purple spots on the skin caused by bleeding under the skin. Like cyanosis, this is a physical finding that can be observed directly.
Choice C rationale:
Dizziness - This is the correct choice. Dizziness is a subjective sensation that the patient experiences. It cannot be directly observed and relies on the patient's description of feeling unsteady, lightheaded, or having a spinning sensation.
Choice D rationale:
Blood pressure - Blood pressure is an objective measurement that can be taken using a blood pressure cuff and a stethoscope or automated device. It is not based on the patient's description and does not fall under subjective data.
Correct Answer is B
Explanation
The correct answer is choice B. Increased anteroposterior diameter of the chest.
Choice A rationale:
Petechiae on the chest (Choice A) are tiny red or purple spots that appear on the skin due to small blood vessel breakage. They are not typically associated with COPD and emphysema. Petechiae are more often related to conditions like thrombocytopenia or certain infections, where blood clotting is impaired.
Choice B rationale:
Increased anteroposterior diameter of the chest, often referred to as "barrel chest," is a characteristic finding in clients with COPD and emphysema. This occurs due to the hyperinflation of the lungs and the loss of elasticity in the lung tissues, which causes the chest to become rounded and the ribs to be positioned more horizontally.
Choice C rationale:
An oxygen saturation level of 96% (Choice C) is within the normal range for oxygen saturation. However, while it's important for clients with COPD to maintain adequate oxygen levels, this value doesn't specifically correlate with the client's symptoms of a wet cough and occasional shortness of breath.
Choice D rationale:
Respiratory alkalosis (Choice D) involves an increase in blood pH due to decreased levels of carbon dioxide (hypocapnia) caused by hyperventilation. While respiratory alkalosis can occur in clients with COPD due to compensatory hyperventilation, it is not a direct assessment finding related to the client's symptoms of a wet cough and occasional shortness of breath.
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