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

Answer and Explanation

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.

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Correct Answer is ["A","B"]

Explanation

Choice A rationale: Bearing the weight of the body on the hands is not the correct technique for using crutches. The weight should be borne on the arms, not the hands.
Choice B rationale: Using crutches that belonged to someone else may not be appropriate as they need to be properly fitted for the individual. Additionally, old crutches may be worn or damaged.
Choice C rationale: This statement is appropriate and does not indicate a need for additional teaching. Keeping spare crutch tips is a good practice, as crutch tips can wear down over time and may need replacement. This demonstrates the client's understanding of the need for maintenance and preparedness.
Choice D rationale: This statement is appropriate and indicates a good understanding of crutch care. Regular inspection of crutches is important to ensure their safety and effectiveness. It allows the client to identify any signs of wear or damage early on and take necessary actions, such as replacing worn-out parts, to prevent accidents or injuries.

A. "You are experiencing stress incontinence. Do you know how to do Kegel exercises?" B. "You are experiencing transient incontinence. Have you been administered diuretics or IV fluids lately?" C. "You are experiencing total incontinence. Have you had any surgeries or trauma that may be causing this?" D. "You are experiencing reflex incontinence. Have you had a spinal cord injury in the past?"

Correct Answer is D

Explanation

Choice A rationale: Stress incontinence is characterized by involuntary urine leakage during activities that increase intra-abdominal pressure, such as coughing or sneezing.
Choice B rationale: Transient incontinence is temporary and often related to factors like medications or medical conditions.
Choice C rationale: Total incontinence refers to continuous and unpredictable leakage of urine.
Choice D rationale: Reflex incontinence is associated with neurologic dysfunction, and the lack of warning or stress preceding involuntary urination aligns with this description.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs additional teaching?

Correct Answer is ["A","B"]

Explanation

Reflex incontinence is associated with neurologic dysfunction and occurs when no warning or stress precedes periodic involuntary urination.

Correct Answer is D

Explanation

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:

When moving a client up in bed with the assistance of another caregiver, the nurse should:

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