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 B
Explanation
Choice A rationale:
While comparing intra-operative data to post-operative outcomes can be valuable for research and quality improvement purposes, it's not the primary purpose of immediate post-operative assessments in the PACU.
The focus in the PACU is on the patient's immediate well-being and stabilization, not on long-term data analysis.
Choice B rationale:
Preventing complications:
Early detection of potential complications is crucial for timely intervention and prevention of adverse events.
Assessments identify changes in vital signs, respiratory status, pain levels, level of consciousness, surgical site integrity, and other indicators of potential complications.
Monitoring and stabilizing the patient:
Nurses closely monitor patients' physiological responses to anesthesia and surgery, ensuring vital signs remain within acceptable ranges and managing any deviations.
They assess pain levels and administer analgesics as needed, promote respiratory function, maintain fluid and electrolyte balance, and address any other post-operative concerns.
Choice C rationale:
While cardiovascular data is indeed crucial in the PACU, it's not the sole focus of assessments.
Nurses assess a comprehensive range of body systems to ensure overall patient stability and recovery.
Choice D rationale:
Determining recovery time is important, but it's secondary to ensuring patient safety and stability.
Assessments prioritize identifying and addressing potential complications, promoting recovery, and ensuring a safe transition from the PACU.
Correct Answer is A
Explanation
Choice A rationale:
The physical dimension encompasses the tangible, biological aspects of an individual, including age, race, gender, genetic inheritance, anatomy, and physiological processes.
Here's a detailed breakdown of how each of these factors aligns with the physical dimension in the context of the patient's hypertension:
Age:
Hypertension is more prevalent in older adults due to natural changes in the cardiovascular system, such as stiffening of arteries and decreased elasticity.
The patient's age of 68 years places him within this higher-risk category.
Race:
African Americans have a disproportionately higher risk of hypertension and related complications compared to other racial groups.
This disparity is attributed to a complex interplay of genetic, environmental, and socioeconomic factors. Gender:
While both men and women experience hypertension, men tend to develop it earlier in life and have a higher lifetime risk.
This difference is partially due to hormonal influences and lifestyle factors.
Genetic inheritance:
Hypertension often has a significant genetic component.
Individuals with a family history of hypertension are more likely to develop the condition themselves, suggesting a role of inherited genes in blood pressure regulation.
Choice B rationale:
The emotional dimension focuses on psychological and mental aspects, including feelings, thoughts, behaviors, and coping mechanisms.
While emotions can certainly influence blood pressure and overall health, they are not directly categorized under the physical dimension in this context.
Choice C rationale:
The environmental dimension addresses external factors that impact health, such as access to healthcare, social support, exposure to pollutants, and community resources.
While these factors can indirectly contribute to hypertension risk, they are not inherent physical characteristics of the individual.
Choice D rationale:
The holistic dimension encompasses a comprehensive view of health, integrating physical, emotional, spiritual, social, and environmental aspects.
While holistic care is essential for managing hypertension, the question specifically asks about the dimension that age, race, gender, and genetic inheritance exemplify, which is most accurately aligned with the physical dimension.
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