Patho Patho #72

Question

Who is at highest risk for development of a pressure ulcer?

Answers

  1. A 16 year old female who is in labor with her first child.
    • Rationale:

      This answer choice is not correct because this client only has one identifiable risk factor for pressure wound development: immobility due to labor.

  2. A 72 year old female admitted with a deep vein thrombosis.
    • Rationale:

      This answer choice is not correct because this client only has two risk factors for development of a pressure wound: advanced age and bedrest for the presence of a deep vein thrombosis.

  3. A 50 year old male who is on bed-rest due to a myocardial infarction.
    • Rationale:

      This answer choice is not correct because this client only has two identifiable risk factors for the development of a pressure wound: bedrest and male gender.

  4. A thin, 82 year old male who is confused to person, place, and time.
    • Rationale:

      This answer is correct because this client has four identifiable risk factors for the development of a pressure wound: thin, male gender, advanced age, and confusion.

Overview

The focus of this question is asking the nurse to identify which client has the most risk factors for developing a pressure wound. Risk factors include advanced age, nutritional deficiencies, altered mental status, incontinence,male gender and immobility. An 82 year old male client who is confused has the most risk factors included in this group of clients.

Explanation

Learning Outcomes

Pressure wounds are preventable with frequent skin assessments and ensuring the clients are turned at least every two hours. Every client who is admitted to the hospital is assessed for their pressure wound risk during the initial admission assessment. Clients who are of advanced age, critically ill, confused/ altered mental status, incontinent, and/or immobile are at increased risk for developing pressure wounds.

Test Taking Tip

When answering risk factor questions, always count each risk factor for each client before choosing an answer.

Video Rationale