a nurse is reviewing the health history of an older adult who has a hip fracture what is a risk of developing pressure injuries a nurse is reviewing the health history of an older adult who has a hip fracture what is a risk of developing pressure injuries
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN

1. A healthcare professional is reviewing the health history of an older adult who has a hip fracture. What is a risk factor for developing pressure injuries?

Correct answer: B

Rationale: Urinary incontinence is a risk factor for developing pressure injuries due to prolonged skin exposure to moisture and irritants. Dehydration (choice A) can contribute to skin dryness but is not a direct risk factor for pressure injuries. Poor nutrition (choice C) can affect wound healing but is not specifically linked to pressure injuries. Poor tissue perfusion (choice D) can increase the risk of tissue damage but is not as directly associated with pressure injuries as urinary incontinence.

2. A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?

Correct answer: D

Rationale: The correct answer is D: Airborne. Tuberculosis is spread through small droplets that remain airborne for longer periods, hence requiring airborne precautions. Choice A - Contact precautions are used for diseases spread by direct or indirect contact. Choice B - Droplet precautions are for diseases transmitted by large respiratory droplets that can travel short distances. Choice C - Protective isolation is not necessary for tuberculosis, as it is not spread through contact with the client.

3. Which type of family-nurse contact will provide you with the best opportunity to observe family dynamics?

Correct answer: C

Rationale: The best opportunity to observe family dynamics is through a home visit. This setting allows the nurse to observe the family in their natural environment, providing valuable insights into their relationships, interactions, and living conditions. By being present in the home, the nurse can better understand the family dynamics, communication patterns, and potential stressors that may not be evident in other forms of contact such as clinic consultations, group conferences, or written communication.

4. A nurse is reviewing the medical records of a group of older adult clients. The nurse should identify which of the following as a risk factor for developing infections?

Correct answer: B

Rationale: The correct answer is B: Lowered immune system function. In older adults, a decline in immune system function increases the risk of developing infections. Increased physical activity (choice A) and proper nutrition (choice D) generally support immune function and overall health, reducing the risk of infections. Regular health screenings (choice C) are important for early detection of health issues but do not directly increase the risk of infections.

5. A client with a new diagnosis of chronic kidney disease is being taught about dietary management. Which of the following statements should be included in the teaching?

Correct answer: B

Rationale: In chronic kidney disease, decreasing the intake of phosphorus-rich foods is essential as impaired kidney function can lead to difficulty in excreting phosphorus, causing an imbalance. This can result in bone and heart complications. Therefore, educating the client to reduce phosphorus intake is crucial for managing the disease and preventing further complications. Option A is incorrect because excessive protein intake can burden the kidneys. Option C is not directly related to the management of chronic kidney disease. Option D is also incorrect as potassium intake may need to be limited in certain stages of kidney disease.

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