A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development?
a. A 44-year-old prescribed IV antibiotics for pneumonia
b. A 26-year-old who is bedridden with a fractured leg
c. A 65-year-old with hemi-paralysis and incontinence
d. A 78-year-old requiring assistance to ambulate with a walker
ANS: C
Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 65-year-old the person at highest risk.
You might also like to view...
What is the priority in the discharge plan for a child with immune thrombocytopenic purpura (ITP)?
a. Teaching the parents to report excessive fatigue to the physician b. Monitoring the child's hemoglobin level every 2 weeks c. Providing a diet that contains iron-rich foods d. Establishing a safe, age-appropriate home environment
What type of wound would the nurse expect to find in a patient who has a wound healing by primary intention?
A) A surgical wound with a large amount of exudate B) A large abraded area that is infected C) A pressure ulcer with pink granulation tissue in the wound bed D) A surgical wound that is clean and well-approximated
The nurse is teaching a group of adolescents about sun protection. What information will the nurse include when teaching this group?
a. Effective sunscreens guard against melanoma and basal cell carcinoma. b. SPF numbers indicate UVB protection, and UVA protection is assumed for all products. c. SPF ratings are proportional to the amount of UVB radiation that they block. d. Sunscreen products of all SPF ratings will protect for 2 hours if not exposed to moisture.
What organs are affected by the type of necrosis that results from either severe ischemia or chemical injury?
a. Lungs b. Brain c. Kidneys d. Muscles e. Heart