Which client is at the greatest risk for pressure injury development?
A 44yearold prescribed antibiotics for pneumonia
A 26yearold bedridden client with a fractured leg
A 65yearold with hemiparesis and incontinence
A 78yearold requiring assistance to ambulate with a walker
The Correct Answer is C
Choice A reason: A 44yearold prescribed antibiotics for pneumonia is not at the greatest risk for pressure injury development, because he or she does not have any major risk factors for pressure injury. Pressure injury is a localized damage to the skin and underlying tissues caused by pressure, shear, friction, or moisture. Antibiotics for pneumonia do not directly affect the skin integrity or blood circulation, nor do they impair the mobility or sensation of the client.
Choice B reason: A 26yearold bedridden client with a fractured leg is at a high risk for pressure injury development, but not the greatest, because he or she has only one major risk factor for pressure injury. Bedridden status is a major risk factor for pressure injury, because it causes prolonged pressure on the bony prominences, such as the sacrum, heels, or hips, which can impair blood flow and oxygen delivery to the skin and tissues. However, the client's age, fracture, and mobility may mitigate some of the risk, as he or she may have better skin elasticity, wound healing, and ability to reposition.
Choice C reason: A 65yearold with hemiparesis and incontinence is at the greatest risk for pressure injury development, because he or she has multiple major risk factors for pressure injury. Age is a risk factor for pressure injury, because it causes decreased skin elasticity, thickness, and vascularity, which can affect the skin's resilience and repair. Hemiparesis is a risk factor for pressure injury, because it causes reduced mobility, sensation, and muscle mass, which can affect the client's ability to reposition, feel pain, and maintain tissue perfusion. Incontinence is a risk factor for pressure injury, because it causes moisture, irritation, and infection of the skin, which can weaken the skin barrier and delay wound healing.
Choice D reason: A 78yearold requiring assistance to ambulate with a walker is at a moderate risk for pressure injury development, but not the greatest, because he or she has only one major risk factor for pressure injury. Age is a risk factor for pressure injury, as explained above. However, the client's ambulation and assistance may reduce some of the risk, as he or she may have less pressure, shear, and friction on the skin and tissues, and more blood circulation and oxygen delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the best intervention because it is timeconsuming and may not be feasible in some situations. Writing down the message can also be impersonal and may not convey the tone or emotion of the speaker. The nurse should use verbal communication as much as possible and supplement it with nonverbal cues, such as gestures, facial expressions, and eye contact.
Choice B reason: This is an incorrect intervention because it can be annoying and ineffective. Talking loudly in the impaired ear can cause discomfort and distortion of the sound. It can also damage the remaining hearing in the ear. The nurse should not shout or raise their voice, but rather speak at a normal volume and enunciate clearly.
Choice C reason: This is the best intervention because it enhances the quality and clarity of the verbal message. Speaking slowly and clearly while facing the client allows the client to see the nurse's mouth movements and facial expressions, which can help them understand the words and the meaning. The nurse should also avoid covering their mouth or chewing gum while speaking.
Choice D reason: This is not the best intervention because it can be inconvenient and impractical. Talking in a regular voice in the good ear may require the nurse to move around the client or position themselves in a certain way. It can also make the client feel isolated or singled out. The nurse should try to communicate with the client in a way that is comfortable and respectful for both parties.
Correct Answer is C
Explanation
Choice A reason: Purulent exudate is a thick, yellowgreen, or brown pus that indicates infection. It is not bloodtinged and does not drip from the wound.
Choice B reason: Serous exudate is a clear, thin, and watery fluid that is normal in the inflammatory stage of wound healing. It does not contain blood cells and is not red in color.
Choice C reason: Serosanguineous exudate is a pink or red fluid that contains both serum and blood. It is common in the proliferative stage of wound healing and may drip from the wound due to increased capillary permeability.
Choice D reason: Sanguineous exudate is a bright or dark red fluid that consists mostly of blood. It indicates active bleeding and is usually seen in traumatic or surgical wounds. It is not diluted with serum and is more viscous than serosanguineous exudate.
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