A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?
A client 92 years of age who uses a walker, is incontinent, and has an extensive cardiac history
A client 45 years of age who has paraplegia
A client 68 years of age who is comatose due to a traumatic brain injury
A client 75 years of age who uses a cane and has dementia
The Correct Answer is A
Choice A rationale: The client who is 92 years old, uses a walker, is incontinent, and has an extensive cardiac history is at higher risk for the development of pressure injuries due to age, immobility, and additional risk factors.
Choice B rationale: A client with paraplegia may be at risk for pressure injuries, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.
Choice C rationale: A comatose client with a traumatic brain injury is at risk, but other factors in Choice A contribute to a higher overall risk.
Choice D rationale: A client who uses a cane and has dementia may be at risk, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Stage III pressure ulcers involve full-thickness tissue loss with visible fat but do not extend to the underlying muscle.
Choice B rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed muscle, bone, or other structures.
Choice C rationale: Stage II pressure ulcers involve partial-thickness skin loss but do not extend into the deeper layers.
Choice D rationale: Unstageable ulcers have a base covered by slough or eschar, making it difficult to assess the depth of tissue involvement. In this case, the wound's base is described as muscle, indicating a stage IV pressure ulcer.
Correct Answer is A
Explanation
Choice A rationale: The statement "I need to void after sexual intercourse to flush microorganisms away from my urethra" is correct. Voiding after sexual intercourse can help prevent the ascent of microorganisms into the urethra and reduce the risk of urinary tract infections.
Choice B rationale: Wearing snug-fitting pants can contribute to a warm and moist environment, potentially increasing the risk of urinary tract infections rather than preventing them.
Choice C rationale: Wiping from the anus to the vagina after going to the bathroom can introduce microorganisms into the urethral area, increasing the risk of urinary tract infections.
Choice D rationale: Frequent bubble baths can disrupt the natural balance of microorganisms in the genital area and increase the risk of urinary tract infections.
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