The nurse understands that certain clients are more susceptible to pressure ulcer development. Which of the following clients would be at an increased risk? Select all that apply
1. Clients who have restricted activity
2. Clients with decreased sensation
3. Clients with poor nutrition
4. Clients who are very thin
5. Clients who have urinary or fecal incontinence
1. Clients who have restricted activity
2. Clients with decreased sensation
3. Clients with poor nutrition
4. Clients who are very thin
5. Clients who have urinary or fecal incontinence
Rationale: Clients who have restricted activity. Clients who have restricted activity, as would occur with quadriplegia, strokes, and fractured hips, are at risk for pressure ulcer development. Clients with decreased sensation. Decreased sensation prevents clients from feeling the pain associated with the development of a pressure ulcer, which increases the risk of development and progression. Clients with poor nutrition. Clients with poor nutrition are more susceptible to pressure ulcer development. Clients who are very thin. Clients who are very thin or have decreased protein in the diet have skin that is more likely to ulcerate. Clients who have urinary or fecal incontinence. Clients who have urinary or fecal incontinence or are exposed to other types of moisture such as perspiration, wound drainage, or emesis are more prone to ulcers.
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