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 A
Explanation
A. "I will reduce my intake of vitamin K-rich foods."
Vitamin K is essential for bone health as it helps in the regulation of calcium within bones and blood vessels. Therefore, reducing the intake of vitamin K-rich foods would not be beneficial for preventing osteoporosis. In fact, adequate intake of vitamin K is important for bone health.
B. "I will limit my intake of soft drinks." - Soft drinks, especially cola beverages, contain phosphoric acid, which can leach calcium from bones, making them weaker and more susceptible to fractures.
C. "I will reduce my intake of sodium." - High sodium intake can lead to increased calcium excretion in the urine, potentially weakening bones over time. Reducing sodium intake can help in preventing bone loss.
D. "I will decrease my intake of caffeine." - Excessive caffeine consumption can interfere with calcium absorption, contributing to bone loss. Decreasing caffeine intake is advisable for maintaining bone health.
Correct Answer is B
Explanation
A. Recent travel: Assessing recent travel history is relevant in understanding potential exposure to certain infections or dietary habits specific to certain regions. However, for a client admitted with renal stones, the immediate focus is on understanding factors related to their condition. While travel history might be a part of the overall assessment, it is not the priority question in this context.
B. Typical diet and fluid intake history: This is the priority question. Understanding the client's typical diet, including the types of foods they consume and their fluid intake habits, is crucial. Certain dietary factors, such as high intake of oxalate-rich foods or insufficient fluid intake, can contribute to the formation of renal stones. Gathering this information helps healthcare providers identify potential dietary factors that might have led to the stones, allowing for tailored dietary recommendations and prevention strategies.
C. Vaccination records: Vaccination records are essential for preventive healthcare, but they are not directly related to the assessment of a client admitted with renal stones. While ensuring clients are up-to-date with vaccinations is important, it is not the immediate concern in the context of renal stones.
D. Last bowel movement: Bowel movements are relevant to overall health and can provide information about gastrointestinal function. However, in the specific context of assessing a client admitted with renal stones, understanding the client's bowel movements is not the primary concern. The focus should be on factors directly related to renal stones, such as diet and fluid intake history, which can inform immediate interventions and prevention strategies.
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