RN Nursing · Pressure Injuries and Wound Management · Practice question
A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?
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Stiffness in the lower extremities.
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Difficulty hearing some types of sounds.
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Difficulty moving the upper extremities.
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✓
A reddened area over the sacrum.
Answer & explanation
Correct: A reddened area over the sacrum.
A client who is immobile following a stroke is at high risk for numerous complications, and the nurse's monitoring priorities should reflect the most serious and preventable risks. A reddened area over the sacrum is a stage 1 pressure injury — the earliest detectable sign of tissue damage caused by sustained pressure over a bony prominence. The sacrum is one of the most vulnerable sites in a bedridden or chair-bound client because it bears significant weight in the supine position and has little protective tissue. Early identification allows the nurse to implement repositioning schedules, pressure-relieving surfaces, and skin care to prevent progression to deeper, more serious wounds. Stiffness in the lower extremities, while a concern related to disuse contractures, is not as immediately life-threatening or as directly caused by immobility as pressure injuries. Difficulty hearing is not a recognized complication of immobility and is unrelated to the clinical scenario described. Difficulty moving the upper extremities is related to the neurological deficits from the stroke itself rather than a complication of immobility that the nurse must newly monitor for. Therefore, monitoring for pressure injuries — signaled by reddened skin over bony prominences like the sacrum — is the primary nursing concern in this immobile post-stroke client.
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