A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?
An adolescent who has a cervical fracture and is in a halo brace
A middle adult who has a fractured radius and an arm cast
An older adult who has a hip fracture and is in Buck's traction
A young adult who has a femur fracture and is in skeletal balanced suspension traction
The Correct Answer is C
Rationale:
A. Although the adolescent in a halo brace has some immobility, the greatest risk factors for skin breakdown involve areas where prolonged pressure is applied, and older adults are more vulnerable due to age-related skin changes.
B. A fractured radius and arm cast do not pose a significant risk for skin breakdown because the client can still mobilize and reposition themselves, reducing prolonged pressure.
C. An older adult with a hip fracture in Buck's traction is at greatest risk for skin breakdown due to immobility, pressure from the traction setup, and the reduced skin elasticity and healing capacity that come with age.
D. While skeletal balanced suspension traction poses some risk, a young adult typically has better skin integrity and mobility than an older adult, reducing the risk for skin breakdown.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
Rationale:
A. A guaiac test does not check for parasites. Tests for parasites typically involve microscopic examination of the stool or other specialized tests.
B. Steatorrhea refers to fat in the stool, and this is detected through tests that measure fat content in the stool, not a guaiac test.
C. A guaiac test is specifically used to detect occult (hidden) blood in the stool, which can indicate gastrointestinal bleeding, polyps, or colorectal cancer.
D. Bacteria in the stool is detected through stool cultures, not a guaiac test.
Correct Answer is D
Explanation
Rationale:
A. Adequate nutrition actually promotes wound healing. Poor nutrition, especially a lack of protein and vitamins, delays healing and increases the risk of infection.
B. Chronic wounds heal better in a moist environment rather than a dry one. Moist wound healing promotes cell migration and prevents scab formation, improving healing.
C. Fat tissue does not heal more rapidly. In fact, it heals more slowly due to decreased vascularization, which impairs oxygen delivery and nutrient supply to the tissue.
D. Long-term steroid use diminishes the body’s inflammatory response, reducing the body's ability to initiate the healing process. This delay in inflammation can lead to slower wound healing and a higher risk of infection.