A registered nurse working in a long-term care facility is assessing residents at risk for the development of pressure ulcers.
Which one would be most at risk?
A female client, 86 years of age, who is bed-bound
A male client, 75 years of age, who uses a cane
A female client, 92 years of age, who uses a walker
A male client, 83 years of age, who is mobile
The Correct Answer is A
Choice A rationale:
Immobility: A bed-bound client is at the highest risk for pressure ulcer development due to prolonged pressure on bony prominences. The lack of movement prevents adequate blood flow to the tissues, leading to ischemia and tissue breakdown.
Age: Older adults have thinner, more fragile skin that is more susceptible to injury. They also have decreased subcutaneous fat, which provides less cushioning for bony prominences.
Nutritional status: Malnutrition is a significant risk factor for pressure ulcers, as it impairs wound healing and tissue repair. Incontinence: Urinary and fecal incontinence can irritate the skin and increase the risk of breakdown.
Chronic medical conditions: Many chronic medical conditions, such as diabetes, peripheral vascular disease, and neurological disorders, can impair blood flow and sensation, further increasing the risk of pressure ulcers.
Choice B rationale:
Mobility: A client who uses a cane is still able to ambulate, which helps to redistribute pressure and reduce the risk of pressure ulcers.
Age: While a 75-year-old client is still considered an older adult, they are less likely to be at risk than a bed-bound client.
Choice C rationale:
Mobility: A client who uses a walker is able to ambulate, although their mobility may be limited. This still helps to reduce the risk of pressure ulcers compared to a bed-bound client.
Age: A 92-year-old client is at a higher risk due to their age, but their mobility helps to mitigate this risk. Choice D rationale:
Mobility: A mobile client is at the lowest risk for pressure ulcer development, as they are able to frequently reposition themselves and relieve pressure on bony prominences.
Age: While an 83-year-old client is still considered an older adult, their mobility significantly reduces their risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
While independence is a valuable quality for nurses, it's not the most essential quality for leadership. Effective leaders must be able to collaborate with others, delegate tasks, and build consensus. They must also be able to recognize when they need to seek help or guidance from others.
Choice B rationale:
Physical stamina is important for nurses, as they often work long hours and are on their feet for extended periods. However, it's not the most essential quality for leadership. Leaders need to be able to think clearly, make decisions under pressure, and motivate others, even when they are tired or stressed.
Choice C rationale:
Flexibility is essential for nursing leaders because the healthcare environment is constantly changing. Leaders must be able to adapt to new situations, challenges, and demands. They must also be able to adjust their leadership style to meet the needs of different individuals and teams.
Here are some examples of how flexibility is essential for nursing leaders:
Managing change: Leaders must be able to effectively manage change, such as new policies, procedures, or technologies. They need to be able to communicate changes clearly, provide support to staff, and ensure that changes are implemented smoothly.
Dealing with conflict: Leaders must be able to resolve conflicts effectively, whether between staff members, patients, or families. They need to be able to listen to different perspectives, identify common ground, and find solutions that meet the needs of all parties involved.
Adapting to different personalities: Leaders must be able to work with a variety of personalities and work styles. They need to be able to adjust their communication style, provide feedback, and motivate individuals in a way that is tailored to their needs.
Responding to crises: Leaders must be able to act quickly and decisively in crisis situations. They need to be able to assess the situation, make decisions, and take action to protect the safety of patients and staff.
Choice D rationale:
Vulnerability can be a valuable quality for leaders, as it can help to build trust and rapport with others. However, it's not the most essential quality for leadership. Leaders need to be able to balance vulnerability with strength and confidence.
Correct Answer is D
Explanation
Choice A rationale:
Planning is conducted during the initial stage of Lewin's change model, known as the unfreezing phase. This phase involves creating awareness of the need for change, building support, and developing a plan for implementation. It's not part of the refreezing phase.
Choice B rationale:
Change is initiated during the second stage of Lewin's change model, known as the change or transition phase. This phase involves implementing the planned changes, providing training and support, and addressing resistance. It's not part of the refreezing phase.
Choice C rationale:
The need for change is recognized during the unfreezing phase, not the refreezing phase. Recognizing the need for change is a crucial step in initiating the change process, but it's not the focus of the refreezing phase.
Choice D rationale:
Change becomes permanent during the refreezing phase. It involves solidifying the new behaviors and practices that have been implemented during the change phase. This is achieved through various strategies, such as:
Reinforcement of the new behaviors through rewards, recognition, and positive feedback
Integration of the new behaviors into organizational policies, procedures, and structures
Creation of a supportive culture that encourages and sustains the change
Ongoing monitoring and evaluation to ensure that the change is sustained over time
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