Question

the nurse determines an older client is at risk for developing a pressure injury. the nurse understands which factor puts the client at risk? (select all that app

1. urinary continence.
2. ambulation with an assistive device.
3. pronounced bony prominences.
4. early stage alzheimer disease.
5. frequent immobility.
6. low serum albumin.

Explanation:

• Pronounced bony prominences: These areas (e.g., heels, elbows) have less soft - tissue padding, increasing pressure - injury risk.
• Early stage Alzheimer disease: May cause decreased mobility and neglect of body positioning, increasing pressure - injury risk.
• Frequent immobility: Prolonged pressure on tissues without relief (e.g., from repositioning) leads to ischemia and pressure injuries.
• Low serum albumin: Indicates poor nutrition. Malnutrition impairs tissue perfusion and wound - healing, increasing pressure - injury risk.
• Urinary continence: Not a risk factor. Incontinence (urinary or fecal) is a risk factor due to skin maceration.
• Ambulation with an assistive device: Indicates some mobility, which is generally a positive factor (reduces immobility - related pressure - injury risk).

Answer:

1. Pronounced bony prominences, 4. Early stage Alzheimer disease, 5. Frequent immobility, 6. Low serum albumin