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 D
Explanation
A. Increased urinary output: Phenazopyridine (Pyridium) does not directly impact urinary output. Its primary function is to provide relief from urinary pain, burning, and discomfort associated with urinary tract infections (UTIs) or other urinary conditions. It does not affect the amount of urine a person produces.
B. Decreased WBC's: Phenazopyridine does not directly influence white blood cell count (WBCs). WBC count is an indicator of the body's immune response and is typically used to assess the presence of infection. Phenazopyridine provides symptomatic relief but does not affect the underlying infection or the body's immune response to it.
C. Increased uric acid: Phenazopyridine does not affect uric acid levels. Uric acid is a waste product that is excreted by the kidneys. Elevated uric acid levels can be associated with conditions like gout, but Phenazopyridine does not have any direct impact on these levels.
D. Decreased bladder pain/spasms: Phenazopyridine is intended to relieve symptoms such as bladder pain, spasms, burning sensation, and discomfort experienced during urination. Therefore, the effectiveness of Phenazopyridine is indicated by a reduction in these symptoms. If the patient reports a decrease in bladder pain and spasms, it suggests that the medication is working to alleviate the discomfort associated with urinary tract issues.
Correct Answer is D
Explanation
A. Lordosis: Lordosis is an inward curvature of the spine, commonly seen in the lower back (lumbar spine) or neck (cervical spine). It creates a swayback appearance. Lordosis is not typically associated with osteoporosis.
B. Scoliosis: Scoliosis is a sideways curvature of the spine, creating an "S" or "C" shape. While scoliosis can occur in people of all ages, it is not directly caused by osteoporosis.
C. Ankylosis: Ankylosis refers to the stiffening or fusion of joints, often due to inflammation and progressive loss of function. It is not a spinal deformity associated with osteoporosis.
D. Kyphosis: Kyphosis is a forward rounding of the back, leading to a hunched or humpbacked posture. It commonly affects the upper back (thoracic spine) and is associated with osteoporosis, especially in older adults. When the bones in the spine weaken due to osteoporosis, they can compress and collapse, leading to the development of kyphosis. This condition is sometimes referred to as a dowager's hump when it occurs in older women.
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