The nurse understands that certain patients are more susceptible to pressure ulcer development. Which clients should the nurse identify as being at an increased risk for this health problem? Select all that apply.
Client with restricted activity
Client who can ambulate
Client with a cast
Client with good nutrition
Client with urinary and fecal incontinence
Correct Answer : A,C,E
A. Client with restricted activity - Patients with limited mobility are at a higher risk for pressure ulcers because they are unable to change positions easily, leading to prolonged pressure on certain body parts.
B. Client who can ambulate - Patients who can ambulate have the ability to shift their body weight and change positions, reducing the risk of prolonged pressure on specific areas. Ambulation can improve circulation and reduce the risk of pressure ulcers
C. Client with a cast - Clients with casts are often limited in their ability to move or change positions, making them susceptible to pressure ulcers in areas where the cast creates pressure points on the skin.
D. Client with good nutrition - Proper nutrition is essential for overall health, including skin health. Adequate nutrition promotes wound healing and tissue repair. Good nutrition is not a risk factor for pressure ulcers; in fact, it can contribute to preventing them by maintaining healthy skin.
E. Client with urinary and fecal incontinence - Incontinence can lead to moisture on the skin, making it more susceptible to breakdown. Prolonged exposure to moisture, especially in the presence of urine or feces, can increase the risk of pressure ulcer development.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["84.1"]
Explanation
Weightinkg=185÷2.2≈84.1
Calculate the dose of enoxaparin:
The prescribed dose is 1 mg/kg.
Doseinmg=Weightinkg×Doseperkg
Doseinmg=84.1×1≈84.1
The nurse should administer 84.1 mg of enoxaparin.
Correct Answer is D
Explanation
A. Increase sodium intake - This is not a preventive measure for osteoporosis. High sodium intake can lead to increased calcium excretion and weaken bones.
B. Drink a cup of coffee each morning - Caffeine consumption, especially in excess, can interfere with calcium absorption and increase calcium excretion. Limiting caffeine intake is recommended for bone health. Drinking coffee in moderation is acceptable but excessive consumption should be avoided.
C. Have a bone-density scan each year - While bone-density scans (DEXA scans) are useful for diagnosing osteoporosis or assessing bone health, they are not typically recommended for young adults with a family history of osteoporosis unless there are specific risk factors present. Yearly scans are unnecessary and not cost-effective for young adults without significant risk factors.
D. Engage in weight-bearing exercise regularly - Weight-bearing exercises, such as walking, jogging, dancing, and resistance training, help to increase bone density and strength. Regular physical activity, especially weight-bearing exercises, is a recommended preventive measure against osteoporosis.
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