The nurse assesses assigned patients and determines which patient is at highest risk for altered skin integrity?
a. Young adult in traction who has a low-protein diet and dehydration
b. Elderly patient diagnosed with well-controlled type 2 diabetes
c. Middle-aged adult with metabolic syndrome taking antihypertensives
d. Adolescent in bed with influenza having periods of high fever and diaphoresis
A
The young adult patient in traction has multiple risk factors including immobility, dehydration, and inadequate protein intake. Healthy skin depends on adequate protein levels to maintain the skin, repair minor defects, and preserve intravascular volume. Therefore, this patient is at greatest risk for altered skin integrity. An elderly patient with well-controlled diabetes has only one risk factor, and therefore is not at highest risk among the group of patients in the scenario. The middle-aged adult with metabolic syndrome, which involves obesity, hyperlipidemia, and hypertension, has compromised health, although not necessarily compromised skin integrity—unless the patient were immobile, which he is not. Although fever and skin moisture can compromise skin integrity, the adolescent's condition is likely transient.
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