Which older adult on bed rest is most at risk to develop skin breakdown? A client who:.
Applies powder after drying the skin.
Has been NPO for four days.
Bathes twice a week.
Has hypertension.
The Correct Answer is B
A client who has been NPO for four days is most at risk to develop skin breakdown. This is because being NPO (nothing by mouth) can lead
to malnutrition and dehydration, which are both risk factors for bedsores. Malnutrition can impair the skin’s ability to heal and resist infection, while dehydration can make the skin dry and fragile.
Choice A is wrong because applying powder after drying the skin can help prevent moisture and friction, which are also risk factors for bedsores.
Choice C is wrong because bathing twice a week may not be frequent enough to keep the skin clean and free of irritants, which can also contribute to bedsores.
Choice D is wrong because hypertension (high blood pressure) does not directly cause bedsores, although it may be associated with other conditions that affect blood circulation and tissue oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
Olanzapine is an antipsychotic drug that can cause weight gain and increased blood sugar as common side effects.
Therefore, the nurse should monitor the client’s weight and blood sugar regularly to prevent complications such as obesity and diabetes.
Choice B is wrong because olanzapine does not affect skin turgor, which is a measure of hydration status.
Choice C is wrong because olanzapine does not cause falls, although it may cause dizziness or unsteadiness as side effect.
Choice D is wrong because olanzapine does not cause significant changes in blood pressure, although it may cause orthostatic hypotension (a drop in blood pressure when standing up) as a side effect.
Correct Answer is C
Explanation
“I have limited my alcohol intake before bedtime.”. This statement shows that the client understands that alcohol can interfere with sleep quality and quantity. Alcohol can disrupt the normal sleep cycle and cause frequent awakenings, nightmares, or insomnia.
Choice A is wrong because sleeping in most mornings can disrupt the regular sleep schedule and make it harder to fall asleep at night. It is better to keep a consistent bedtime and wake time, even on weekends.
Choice B is wrong because working on the computer before going to bed can expose the client to blue light, which can suppress the production of melatonin, a hormone that regulates sleep. It is better to avoid screens and other stimulating activities at least an hour before bedtime.
Choice D is wrong because watching television for 1 hour before sleeping can also expose the client to blue light and interfere with sleep onset. It is better to engage in relaxing activities such as reading, listening to soothing music, or meditating before sleeping.
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