Evolve HESI Practice Exam

What finding should the nurse recognize as a risk factor for pressure ulcers in a client who has been bedridden for a week?

1. Presence of dry skin

2. Brittle nails

3. Rashes in the axillary, groin, and skin fold regions

4. Shiny hairless skin

The correct answer is: Rashes in the axillary, groin, and skin fold regions

The presence of rashes in the axillary, groin, and skin fold regions is a significant risk factor for pressure ulcers in a client who has been bedridden for a week. Rashes in these high-friction areas can indicate skin irritation and breakdown, which are exacerbated by prolonged immobility. When a patient is bedridden, they are at risk for pressure injuries due to constant pressure on certain areas of the skin, especially where skin rubs together or where there are skin folds. Moisture from rashes can further contribute to skin maceration, making it more susceptible to ulceration. In the context of other options, while dry skin can also be a risk factor, it is more generalized and may not directly indicate immediate threat compared to rashes that suggest ongoing irritation and vulnerability. Brittle nails do not significantly contribute to the risk of pressure ulcers. Shiny hairless skin may suggest a lack of blood supply or a stage of skin breakdown, but it does not specifically denote the presence of a rash that would actively compromise skin integrity in the way that rashes do.