Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following information should the nurse include?
A. Increase in skin thinning.
An increase in skin thinning is not a typical age-related change in the skin. In older adults, skin tends to become thinner due to a decrease in subcutaneous tissue, making it more fragile and susceptible to damage.
B. Increase in skin elasticity.
An increase in skin elasticity is not a common characteristic of aging skin. In fact, older adults often experience a decrease in skin elasticity, leading to wrinkles and sagging skin.
C. Decrease in subcutaneous tissue.
D. Increase in blood supply to skin.
While there may be changes in blood supply to the skin as people age, an increase in blood supply is not a well-established or typical age-related change. Decreased blood flow to the skin is more common in older adults.
E. Decrease in skin hydration.
Decrease in skin hydration is a common age-related change, but it's not the most significant change mentioned in the question. The primary focus in older adults is the decrease in subcutaneous tissue, which has a more direct impact on skin health.
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Full Explanation
Choice A rationale:
An increase in skin thinning is not a typical age-related change in the skin. In older adults, skin tends to become thinner due to a decrease in subcutaneous tissue, making it more fragile and susceptible to damage.
Choice B rationale:
An increase in skin elasticity is not a common characteristic of aging skin. In fact, older adults often experience a decrease in skin elasticity, leading to wrinkles and sagging skin.
Choice D rationale:
While there may be changes in blood supply to the skin as people age, an increase in blood supply is not a well-established or typical age-related change. Decreased blood flow to the skin is more common in older adults.
Choice E rationale:
Decrease in skin hydration is a common age-related change, but it's not the most significant change mentioned in the question. The primary focus in older adults is the decrease in subcutaneous tissue, which has a more direct impact on skin health.
Similar Questions
A nurse is teaching a newly licensed nurse about incident reports.
The nurse should include that which of the following events requires an incident report?
A. An IV medication is administered via an oral route.
Administering IV medication via an oral route is a medication error and should be reported.
B. A client vomits their morning medications.
A client vomiting their morning medications is an adverse event, but not all adverse events require an incident report. The nurse should assess the situation and report if it poses a risk to the patient's health.
C. A lipid-lowering medication is administered to a client 1 hr after the scheduled time.
Administering a lipid-lowering medication to a client one hour after the scheduled time is a medication error, but again, the need for an incident report depends on the potential harm to the patient.
D. A client has an allergic reaction to an antibiotic.
An allergic reaction can occur in clients with no known drug allergies. Unless a drug was given in known allergies, it does not require an incident report.
Full Explanation
Choice A rationale:
Administering IV medication via an oral route is a medication error and should be reported.
Choice B rationale:
A client vomiting their morning medications is an adverse event, but not all adverse events require an incident report. The nurse should assess the situation and report if it poses a risk to the patient's health.
Choice C rationale:
Administering a lipid-lowering medication to a client one hour after the scheduled time is a medication error, but again, the need for an incident report depends on the potential harm to the patient. In some cases, reporting this incident may be necessary.
Choice D rationale
An allergic reaction can occur in clients with no known drug allergies. Unless a drug was given in known allergies, it does not require an incident report.
A nurse is caring for a client who has phantom limb pain.
The nurse should identify the client is experiencing which type of pain?
A. Neuropathic pain.
B. Acute pain.
Acute pain is typically associated with a sudden injury or condition, and it is usually short-term and self-limiting. Phantom limb pain is a chronic condition that is often neuropathic in nature.
C. Cancer pain.
Cancer pain is generally associated with the presence of a tumor or cancer-related treatment. Phantom limb pain is not directly related to cancer.
D. Chronic pain.
Chronic pain is a broad category that includes various types of long-lasting pain, but in the case of phantom limb pain, it is specifically neuropathic in nature. Neuropathic pain originates from damage or dysfunction of the nervous system and is a common characteristic of phantom limb pain. .
Full Explanation
Choice B rationale:
Acute pain is typically associated with a sudden injury or condition, and it is usually short-term and self-limiting. Phantom limb pain is a chronic condition that is often neuropathic in nature.
Choice C rationale:
Cancer pain is generally associated with the presence of a tumor or cancer-related treatment. Phantom limb pain is not directly related to cancer.
Choice D rationale:
Chronic pain is a broad category that includes various types of long-lasting pain, but in the case of phantom limb pain, it is specifically neuropathic in nature. Neuropathic pain originates from damage or dysfunction of the nervous system and is a common characteristic of phantom limb pain. .
A nurse is assessing a client who has impaired mobility.
The nurse should monitor the client for a pressure injury due to which of the following factors?
A. Increased collagen.
Increased collagen. Increased collagen is not a risk factor for pressure injuries. Collagen provides strength and support to the skin and tissues, which can be protective against pressure injuries by maintaining tissue integrity.
B. Decreased circulation.
Decreased circulation. Decreased circulation is a significant risk factor for pressure injuries. When blood flow to a specific area is reduced, it can lead to tissue ischemia, which makes the tissue more vulnerable to pressure damage. The lack of oxygen and nutrients from reduced circulation impairs the skin's ability to withstand pressure, increasing the risk of pressure injury development.
C. Increased muscle mass.
Increased muscle mass. While having increased muscle mass can offer some protection against pressure injuries due to the added support and padding, it is not a primary risk factor for developing pressure injuries. In fact, individuals with increased muscle mass may be less prone to pressure injuries because their muscle tissue helps distribute pressure more evenly.
D. Decreased serum calcium.
Decreased serum calcium. Decreased serum calcium levels can affect muscle function and bone health but are not a direct risk factor for pressure injuries. Pressure injuries primarily result from sustained pressure on the skin and underlying tissues, often due to immobility and other factors. Calcium levels are not directly related to the development of pressure injuries.
Full Explanation
Choice A rationale:
Increased collagen. Increased collagen is not a risk factor for pressure injuries. Collagen provides strength and support to the skin and tissues, which can be protective against pressure injuries by maintaining tissue integrity.
Choice B rationale:
Decreased circulation. Decreased circulation is a significant risk factor for pressure injuries. When blood flow to a specific area is reduced, it can lead to tissue ischemia, which makes the tissue more vulnerable to pressure damage. The lack of oxygen and nutrients from reduced circulation impairs the skin's ability to withstand pressure, increasing the risk of pressure injury development.
Choice C rationale:
Increased muscle mass. While having increased muscle mass can offer some protection against pressure injuries due to the added support and padding, it is not a primary risk factor for developing pressure injuries. In fact, individuals with increased muscle mass may be less prone to pressure injuries because their muscle tissue helps distribute pressure more evenly.
Choice D rationale:
Decreased serum calcium. Decreased serum calcium levels can affect muscle function and bone health but are not a direct risk factor for pressure injuries. Pressure injuries primarily result from sustained pressure on the skin and underlying tissues, often due to immobility and other factors. Calcium levels are not directly related to the development of pressure injuries.