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 B
Explanation
Choice A rationale: Carrying an air-filled ball while wading through the water across the width of a pool is an isotonic exercise.
Choice B rationale: Contracting the gluteal muscles while holding a simple yoga pose is an isometric exercise.
Choice C rationale: Walking at a rate of 3 miles (5 km)/hour around a racetrack is an isotonic exercise.
Choice D rationale: Sitting in a chair with a low weight on the side and lifting the knee to the seat level of the chair is an isotonic exercise.
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