The nurse conducting a pressure ulcer risk assessment on clients in a long-term care facility identifies which of the following as risk factors? Select all that apply. Standard Text: Select all that apply
1. Elevated temperature of 101°F
2. Decreased response to painful stimuli
3. Consumes a high-protein diet.
4. Drinks six glasses of water daily.
5. Walks occasionally for a short distance.
1,2,5
Rationale: An elevated temperature puts the client at risk due to the increased need for oxygen to the tissues. The client who has limited sensory response is at risk because she does not feel the pain associated with compressed tissues. A client who walks only occasionally is at risk because the client is in bed or a chair for the majority of the time. The client who consumes adequate protein and fluids is not at a high risk, although assessment in the elderly for pressure ulcers is a priority.
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