an elderly client who is up to the chair for meals with assistance
a 24-year-old client with diabetes whose hemoglobin A1C is 6.4%
a client who is legally blind and lives independently, except for driving
a client with severe right-sided weakness from a stroke and residual peripheral neuropathy
a client who had a right pneumothorax and has a chest tube and can reposition independently
Number 4 is correct.
Rationale: A client with severe weakness on one side will have difficulty turning and repositioning without assistance and will require turning and skin assessment every 2 hours. Neuropathy affects the client’s ability to feel pain and causes damage to the skin to be less apparent to the client. An elderly client who can get up with assistance has more mobility than one with weakness and neuropathy. Younger clients tend to be at lower risk of skin breakdown, and although this client has diabetes, his hemoglobin A1C reflects well-controlled blood sugars. Being blind is not necessarily a risk factor for skin breakdown, especially in the client who is able to live independently. Although the client with the chest tube may have diminished mobility, the ability to reposition independently minimizes the risk of skin breakdown from lying in one position too long.
