Exhibits
Complete the following sentence by using the list of options.
Mrs. Thompson is at high risk for developing
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Mrs. Thompson is at high risk for developing pressure sores evidenced by the client's end-of-life stage and deteriorating condition.
Emotional distress. While emotional distress is common in end-of-life patients, Mrs. Thompson has already expressed her wishes for a peaceful, pain-free death and has family support for decision-making. Emotional distress is not the primary risk factor for physical complications such as pressure sores.
Dehydration. Decreased oral intake is expected in the end-of-life stage, but dehydration does not directly cause pressure sores. While maintaining comfort is important, forced hydration is often avoided as it may not improve the patient’s quality of life.
Pressure sores. Mrs. Thompson’s declining condition and decreased mobility put her at high risk for developing pressure sores. Limited movement reduces circulation to pressure points such as the heels and sacrum, leading to tissue breakdown. Preventive measures such as repositioning and skin care should be prioritized.
Frequent movement and activity. This is incorrect because frequent movement reduces the risk of pressure sores by promoting circulation and relieving pressure on bony areas. Mrs. Thompson's deteriorating condition likely limits her mobility, making this choice inappropriate.
Ability to communicate their needs. This is incorrect because even if a patient can verbalize discomfort, they may still be unable to move independently. Pressure sores develop primarily due to immobility rather than communication barriers.
End-of-life stage and deteriorating condition. This is correct because patients nearing the end of life experience profound weakness, reduced circulation, and prolonged immobility, all of which increase the risk of pressure sores. These factors make skin breakdown prevention a key nursing priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
Grief: A medical condition requiring immediate pharmacological treatment to prevent emotional distress. This is incorrect because grief is a natural emotional response to loss rather than a medical disorder that always requires treatment. While some individuals may develop complicated grief or depression that necessitates therapy or medication, normal grief is a personal and psychological process that varies from person to person.
End-of-life care: An aggressive approach to curing terminal illnesses through extensive medical interventions. This is incorrect because end-of-life care focuses on comfort, dignity, and symptom management rather than curative treatments. At this stage, the goal is to alleviate suffering and honor the patient’s wishes rather than pursue aggressive medical interventions that may no longer be beneficial.
Palliative care: Specialized medical care focused on improving the quality of life for individuals with serious illnesses by managing symptoms, relieving pain, and providing emotional and psychological support. This is correct because palliative care is designed to enhance comfort and quality of life for individuals with serious, chronic, or terminal illnesses. It includes pain management, emotional support, and symptom control, and it can be provided alongside curative treatments or as part of end-of-life care.
Correct Answer is {"dropdown-group-1":"A"}
Explanation
The most likely cause of the client’s condition based on the nurse’s observation is potential physical abuse and neglect by the caregiver.
Potential physical abuse and neglect by the caregiver. The presence of bruises in various stages of healing, malnutrition, poor hygiene, and fearful behavior suggests possible elder abuse and neglect. The caregiver’s agitation when questioned further raises suspicion. The nurse should follow facility protocols and report concerns to appropriate authorities for further investigation.
Medications that cause spontaneous bruising and skin changes in elderly individuals. While aspirin can increase the risk of bruising, it does not explain the signs of malnutrition, poor hygiene, and fearful behavior. These additional findings suggest a broader concern beyond medication side effects.
Poor dietary intake and lack of proper medical care due to the client's advanced age and disease. While dementia and heart disease can contribute to nutritional challenges, they do not account for unexplained bruising, fearfulness, or a caregiver’s defensive behavior. Malnutrition in this case is more likely due to neglect rather than disease progression.
Chronic illness leading to frailty and easy bruising. Chronic illnesses can make elderly individuals more vulnerable to bruising and weakness, but they do not explain poor hygiene, malnutrition, or the client's fearful demeanor, which are more indicative of abuse or neglect.
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