Which client is at the highest risk for developing a decubitus ulcer among the following patients in a long-term care facility?
Which client is at the highest risk for developing a decubitus ulcer among the following patients in a long-term care facility?
A. An incontinent client who had 3 diarrheal stools.
[9%]
B. An 80-year-old ambulatory diabetic client.
[3%]
C. A 79-year-old malnourished client on bed rest.
[82%]
D. An obese client who occasionally uses a wheelchair.
[5%]
Statistics
Subject/Lesson
Subject
Adult Health
Lesson
Integumentary
Client Need
Test Plan
Basic Care and Comfort
Related Topic
Mobility/Immobility
Item Type
Item Type
Analysis
Explanation
Choice C is correct. Prolonged inadequate nutrition causes weight loss, muscle atrophy, and the loss of subcutaneous tissue. These three conditions reduce the amount of padding between the skin and bones, thus increasing the risk of pressure ulcer development. Specifically, inadequate protein, carbohydrates, fluids, zinc, and vitamin C intake contribute to pressure ulcer formation. Immobility resulting from prolonged bed rest is a risk factor. Several factors contribute to the formation of pressure ulcers: friction and shearing, immobility, inadequate nutrition, fecal and urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced age, and certain chronic conditions.
Choice A is incorrect. Stool incontinence can be a source of skin irritation and contribute to pressure ulcer formation. However, it is not the highest risk for developing a decubitus ulcer. A malnourished client on bed rest is at the highest risk.
Choice B is incorrect. While diabetics may develop skin ulcers and experience slower healing times, ambulatory patients are not at risk for developing pressure sores.
Choice D is incorrect. As long as the client is ambulating, occasional wheelchair use and obesity are not significant risk factors for developing a decubitus ulcer.
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2 Key Topics
Pressure Ulcer Risk Factors
