The nurse is assessing the client for pressure ulcer risk. The ...

[penguins]

The nurse is assessing the client for pressure ulcer risk. The client has no sensory deficits, and the skin is dry and not exposed to moisture. The client is, however, confined to bed and is completely immobile and requires moderate assistance in moving.
 
  The client's nutritional status is adequate. Which score documented by the nurse is the most appropriate based on the assessment data?
  1. 14, indicating moderate risk
  2. 15, indicating high risk
  3. 12, indicating risk
  4. 14, indicating high risk

Question 2

The client experiences a burn on the arm that is confined to the skin. How would the nurse describe this burn when documenting this client's care?
 
  1. A clean wound
  2. A dirty or infected wound
  3. A partial-thickness wound
  4. A full-thickness wound

[joneynes]

Answer to Question 1

Correct Answer: 1

The client gets 4 points for lack of sensory deficits, 4 points for dry skin, 1 point for being bedridden, 1 point for immobility, 3 points for adequate nutrition, and 1 point for shear related to needing moderate assistance to move, totaling 14. A score of 15-18 indicates some risk, 13-14 indicates moderate risk, 10-12 indicates high risk, and 9 indicates very high risk. As a result, this client, with a score of 14, is at moderate risk.

Answer to Question 2

Correct Answer: 3

The burn described is a partial-thickness burn if it is confined to the skin or dermis and epidermis. A full-thickness burn involves the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone. There is not enough information provided to know if it is a clean or dirty wound.