The nurse is caring for a client who has right-sided paralysis followi

The nurse is caring for a client who has right-sided paralysis following a stroke. Which of the following factors would be most likely to result in decubitus ulcer formation for this client?

1. Poor nutrition
2. Immobility
3. Reduced hydration
4. Skin secretions

ANSWER

ANS: 2
The client, who has right-sided paralysis, is at increased risk for developing a pressure ulcer be-cause of immobility. When restricted from moving freely, dependent body parts are exposed to pressure, reducing circulation to affected body parts. Also, the inability to turn or change position increases risk for pressure ulcers. Poor nutrition is a risk factor for developing a pressure ulcer but not for this client. This client is not identified as having reduced hydration. Skin secretions in-crease the risk for developing a pressure ulcer. However, this client’s greatest risk factor is having impaired mobility.