You're working on a medical surgical floor. You have the following patients below. Select all the patients below that are at risk for a pressure injury: (Select All that Apply.)
A 5-year-old female who is a quadriplegic.
A 5-year-old with a Braden Scale score of 7.
A 5-year-old female who has controlled diabetes and is ambulating three times a day.
A 35-year-old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint.
Correct Answer : A,B,D
Rationale:
A. A quadriplegic client is at high risk for pressure injuries due to immobility and lack of sensation, which can lead to prolonged pressure on skin and tissues.
B. A Braden Scale score of 7 indicates severe risk for pressure injuries. The lower the Braden score, the higher the risk, with scores less than 9 signifying very high risk.
C. A client with controlled diabetes who is ambulating frequently is not at high risk for pressure injuries because mobility reduces the risk of sustained pressure.
D. A BMI of 13.6 indicates severe underweight status, and incontinence of stool increases moisture, both of which elevate the risk of pressure injuries. Additionally, the splint on the leg may create pressure points.
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Correct Answer is B
Explanation
Rationale:
A. Assisting the client to the bathroom every 2 hours may not support bladder retraining, which aims to increase the time between voids and encourage the client to recognize the need to urinate.
B. Encouraging the client to hold her urine when feeling the urge is a key component of bladder retraining, as it helps to increase bladder capacity and promotes a normal voiding pattern.
C. Restricting oral fluid intake is not recommended, as it can lead to dehydration and may not effectively aid in bladder retraining. Adequate fluid intake is essential for bladder health.
D. Providing adult diapers does not promote bladder retraining; it may enable continued incontinence rather than encouraging the client to regain control over bladder function.
Correct Answer is ["A","C","D","E"]
Explanation
Rationale:
A. A client with right-sided heart failure and 4+ edema is at risk for pressure ulcers due to fluid accumulation, which can impair circulation and increase the likelihood of skin breakdown.
B. A client who is ambulatory is at a low risk for pressure ulcers because frequent movement reduces the risk of prolonged pressure on any one area.
C. A client with type 1 diabetes mellitus and hyperglycemia is at risk for pressure ulcers because high blood glucose levels can impair wound healing and affect skin integrity.
D. A client with protein-calorie malnutrition is at a significant risk for pressure ulcers due to inadequate nutrition, which weakens the skin and impairs the body’s ability to repair tissue damage.
E. A client with postoperative delirium may have decreased mobility and cognitive awareness, making it harder for them to reposition themselves, thereby increasing their risk of pressure ulcers.