A client has been immobile for an extended period due to a spinal cord injury. The nurse is assessing the client for the risk of developing pressure ulcers.
Which statement regarding the client's immobility and pressure ulcer risk is accurate?
"Immobilization has no impact on the risk of pressure ulcer development.".
"The client's sensory deficits will prevent them from developing pressure ulcers.".
"Prolonged immobility increases the risk of pressure ulcers due to decreased tissue perfusion.".
"The client's spinal cord injury will lead to improved blood flow and oxygenation in the skin.".
The Correct Answer is C
Choice A rationale:
"Immobilization has no impact on the risk of pressure ulcer development." This statement is not accurate.
Immobilization significantly increases the risk of pressure ulcer development.
Prolonged pressure on the skin and tissues due to immobility can lead to tissue ischemia and pressure ulcer formation.
Choice B rationale:
"The client's sensory deficits will prevent them from developing pressure ulcers." Sensory deficits, such as those resulting from a spinal cord injury, can actually increase the risk of pressure ulcers.
Patients with sensory deficits may not feel discomfort or pain, making them less likely to reposition themselves and relieve pressure on vulnerable areas.
Choice C rationale:
"Prolonged immobility increases the risk of pressure ulcers due to decreased tissue perfusion." This statement is accurate.
Prolonged immobility reduces tissue perfusion (blood flow) to areas under pressure, increasing the risk of pressure ulcer development.
Choice D rationale:
"The client's spinal cord injury will lead to improved blood flow and oxygenation in the skin." This statement is not accurate.
A spinal cord injury does not lead to improved blood flow and oxygenation in the skin.
In fact, it can contribute to impaired mobility and sensory deficits, which increase the risk of pressure ulcers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale:
Optimizing nutrition and hydration (Choice A) is a crucial intervention for preventing pressure ulcers.
Proper nutrition supports tissue health and wound healing.
Dehydration and malnutrition can increase the risk of developing pressure ulcers or exacerbate existing ones.
Choice B rationale:
Administering antibiotics prophylactically (Choice B) is not a routine intervention for preventing pressure ulcers.
Antibiotics should be used to treat infections when they occur but should not be given prophylactically unless there are specific clinical indications.
Choice C rationale:
Promoting mobility and activity (Choice C) is an effective strategy for preventing pressure ulcers.
Regular position changes and mobility exercises help relieve pressure on vulnerable areas of the skin, reducing the risk of pressure ulcers.
Choice D rationale:
Using appropriate support surfaces and equipment (Choice D) is essential for preventing pressure ulcers in patients at risk.
Support surfaces, such as pressure-reducing mattresses, can help distribute pressure evenly and reduce the risk of tissue damage.
Choice E rationale:
Educating patients, caregivers, and healthcare professionals on prevention strategies (Choice E) is a vital component of pressure ulcer prevention.
Proper education helps raise awareness and ensures that everyone involved in patient care understands the importance of preventive measures.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale:
"Frequent repositioning of the patient." Frequent repositioning is crucial in preventing pressure ulcers.
It helps redistribute pressure on vulnerable areas, reducing the risk of tissue ischemia and damage.
Choice B rationale:
"Maintaining a dry and clean skin surface." Keeping the skin clean and dry is essential in preventing pressure ulcers.
Moisture can contribute to skin breakdown, so maintaining dryness helps preserve skin integrity.
Choice C rationale:
"Applying pressure-relieving cushions or devices." Using pressure-relieving cushions or devices can help distribute pressure more evenly and reduce the risk of pressure ulcers in bedridden patients.
Choice D rationale:
"Increasing the intake of sugar-rich foods." This choice is not appropriate for preventing pressure ulcers.
Increasing sugar-rich foods can lead to complications such as diabetes and should not be a part of pressure ulcer prevention strategies.
Choice E rationale:
"Encouraging immobility in bedridden patients." Encouraging immobility is not a recommended strategy for preventing pressure ulcers.
Immobility increases the risk of pressure ulcers, and caregivers should aim to promote mobility and reposition patients regularly.
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