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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Hypovolemic shock: Hypovolemic shock occurs when there is a significant loss of blood or fluids in the body, leading to insufficient blood volume to maintain normal circulation. Symptoms include rapid heart rate, low blood pressure, confusion, and cold, clammy skin. While hypovolemic shock is a concern in trauma patients, the symptoms described by the client (shortness of breath and chest pain) are not typical of hypovolemic shock.

B. Fat embolism syndrome: Fat embolism syndrome occurs when fat particles are released into the bloodstream, often after a long bone fracture or trauma. These fat particles can block small blood vessels, leading to symptoms such as respiratory distress, confusion, and petechial rash (small red or purple spots under the skin). While fat embolism syndrome is a concern in patients with long bone fractures, the symptoms described by the client are more suggestive of a pulmonary embolism.

C. Venous thromboembolism (VTE): VTE refers to the formation of blood clots in the veins. Deep vein thrombosis (DVT) occurs when a blood clot forms in a deep vein, usually in the legs, while pulmonary embolism (PE) occurs when a clot breaks loose and travels to the lungs. Symptoms of PE can include sudden chest pain, shortness of breath, rapid heart rate, and cough, which may produce bloody or blood-streaked sputum. Given the client's symptoms of shortness of breath and chest pain, VTE, specifically pulmonary embolism, is a significant concern.

D. Compartment syndrome: Compartment syndrome occurs when there is increased pressure within a muscle compartment, leading to reduced blood flow and potential nerve damage. Symptoms can include severe pain, swelling, and numbness or tingling. While compartment syndrome is a complication of fractures, the symptoms described by the client (shortness of breath and chest pain) are not characteristic of compartment syndrome.

A. Necrotic wound B. Trauma C. Venous insufficiency D. Arterial insufficiency

Correct Answer is D

Explanation

The findings of pale and cool skin on the lower legs, along with small circular ulcers on the soles of the feet, are indicative of arterial insufficiency. Arterial insufficiency occurs when there is a decreased blood flow to the extremities, often due to conditions such as atherosclerosis or peripheral arterial disease. This reduced blood flow can result in pale and cool skin, as well as the development of ulcers, which are typically round and have well-defined borders. It is essential to assess and manage arterial insufficiency promptly to prevent complications like tissue necrosis and gangrene.

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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.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has multiple long bone fractures caused by a motor-vehicle crash that happened 24 hr ago. The client tells the nurse he is short of breath and experiencing chest pain. The nurse should assess the client further for which of the following potential complications?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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