33. A 90-year-old client's condition is one of lethargy, poor capillary perfusion, and urinary incontinence. These findings should indicate to a nurse that this client is at greatest risk for:
33. A 90-year-old client's condition is one of lethargy, poor capillary perfusion, and urinary incontinence. These findings should indicate to a nurse that this client is at greatest risk for:
Test-Taking Tip
Ask what the three presenting conditions will cause. Eliminate the options where the client's condition is not a risk factor: tracheobronchial disorders (Answer 1), musculoskeletal problems (Answer 2), and fluid and electrolyte imbalances (Answer 3).
Content Area: Geriatrics, Integumentary; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
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Answer 1 is incorrect because these conditions do not cause aspiration, for which risk factors would come from secretions, food, or fluid. Answer 2 is incorrect because these conditions do not cause contractures. Answer 3 is incorrect because these conditions do not cause dehydration. Answer 4 is correct because all of the conditions are risk factors for skin breakdown—inactivity, poor circulation, and skin wet from urine.
