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 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.
Correct Answer is B
Explanation
Choice A rationale: A client who is confined to bedrest may not need a gait belt as they are not ambulating.
Choice B rationale: A client with leg strength who can cooperate with movement is a likely candidate for a gait belt. This device provides support and stability during ambulation.
Choice C rationale: A client with a thoracic incision may not necessarily need a gait belt for ambulation unless there are specific mobility concerns.
Choice D rationale: A client with an abdominal incision may not necessarily need a gait belt for ambulation unless there are specific mobility concerns.
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