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A nurse is assessing a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?

• Decreased serum calcium

• Increased collagen

• Decreased circulation

• Increased muscle mass

Answer explanation

A. The client who is immobile is at risk for renal calculi due to increased serum calcium

B. The client who is immobile is at risk for a pressure injury due to decreased collagen

C. The client who is immobile is at risk for a pressure injury due to decreased circulation to tissue

D. The client who is immobile is at risk for a pressure injury due to decreased muscle mass

A nurse is caring for a patient with limited mobility. What should the nurse do to prevent pressure injuries in this patient?

• Encourage the patient to stay in one position

• Provide the patient with a low protein diet

• Turn and reposition the patient every 2 hours

• Apply heat to the affected areas

Which of the following is a common sign of a pressure injury in a patient with impaired mobility?

• Increased heart rate

• Reddened, non-blanchable skin

• Increased appetite

• Decreased blood pressure

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury?

• A client who is alert and responsive and eats 25% of each meal

• A client who is unresponsive to verbal commands and changes position occasionally

• A client who makes frequent slight changes in position and walks occasionally

• A client who is receiving enteral feeding and change position independently

Answer explanation

This client is at greatest risk for pressure injury because they have a very limited sensory perception. The nurse should monitor the client for a pressure injury

A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

• Partial-thickness skin loss with red tissue in wound bed

• Full-thickness skin loss with visible adipose tissue

• Intact skin with localized erythema

• Partial-thickness skin loss with muscle visible in wound bed

A nurse is performing a pressure injury risk assessment for a client. Which of the following findings increase the client's risk of a pressure injury?

• BMI of 21

• Peripheral neuropathy

• Immobility

• Hypoperfusion

Answer explanation

A. BMI of 21 is within normal range. Obesity can increase the risk of pressure injury due to decreased blood and lymphatic flow

B. Peripheral neuropathy increases the pt's risk for pressure injury due to decrease in pain related to pressure sensation

C. Immobility increases the pt's risk for a pressure injury due to decreased ability to reposition off bony prominences

D. Hypoperfusion increases the pt's risk for pressure injury due to decreased circulation in tissue

A nurse is providing teaching about calcium to a client who is at risk for osteoporosis. The nurse should inform the client that calcium is stored in which of the following locations?

• Tendons

• Synovial Joints

• Bones

• Red bone marow

Answer explanation

A. Tendons are connective tissue that join muscles to bones

B. Synovial joints are fluid filled capsules that enable movement

C. Calcium is stored in the bone

D. Bone marrow produces WBC, RBC, platelets and macrophages

A nurse is teaching a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include?  

• Orthostatic hypotension increases a client's risk of a fall

• Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10mmHg

• Orthostatic hypotension increases a patient's risk of pulmonary emboli

• Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5mmHg

Answer explanation

A. Orthostatic hypotension is a decrease in blood pressure when a pt changes from lying down to sitting or standing. The drop in BP can cause the pt to become dizzy and increases the pt's risk for a fall

B. Orthostatic hypotension is a decrease in systolic blood pressure of atleast 20mmHg

C. A deep vein thrombosis increases a pt's risk of a pulmonary emboli

A nurse is teaching a newly licensed nurse about age-related changes to vision in older adult clients. Which of the following should the nurse include as an example of an expected age-related change?

• Increased tone of the eye muscles

• Increased flexibility of the lens

• Reduced depth perception

• Reduced thickness of the lens

Answer explanation

A. decrease in tone of eye muscles is an expected age-related change in older adult clients. This change can result in decreased visual acuity and an increased risk of a fall.

B. A decrease in lens flexibility (presbyopia) is an expected age-related change in older adult clients. This change can cause difficulty focusing and an increased risk of a fall.

C.A decrease in depth perception is an expected age-related change in older adult clients. This change can result in an increased risk of tripping and falling.

D.An increase in thickness of the natural lens is an expected age-related change in the older adult clients. This change can result in decreased visual acuity and an increased risk of a fall.

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? Select all that apply

• Contractures of the extremities

• Polyuria

• Diarrhea

• Crackles in the lungs

• Pressure ulcers

Answer explanation

Contractures of the extremities is correct. Contractures of the extremities are a complication of immobility because of disuse of muscles and joints.

Polyuria is incorrect. Polyuria is not a finding in clients who are immobile. Urinary output decreases as immobility is prolonged, resulting in urinary stasis and increased urinary tract infections.

Diarrhea is incorrect. Constipation, not diarrhea, is a complication of immobility, as gastrointestinal motility is decreased.

Crackles in the lungs is correct. Crackles in the lungs are a complication of immobility, due to mucus that collects in the dependent airways. The client often cannot cough effectively and oxygenation status declines.

Pressure ulcers is correct. Pressure ulcers are a complication of immobility, due to increased pressure on skin and bony prominences, which affects tissue metabolism.