A client sustains an injury to his heel while the unlicensed assistive personnel and the nurse are moving him in bed. What force caused the injury?
Shearing or friction
Pressure or gravity
Chemical or pressure
Twisting and bending
The Correct Answer is A
Choice A reason: Shearing or friction is the force that caused the injury, because it occurs when the skin and underlying tissues move in opposite directions, such as when the client slides down in bed. Shearing or friction can damage the blood vessels and reduce blood flow to the skin, resulting in tissue ischemia, necrosis, and ulceration.
Choice B reason: Pressure or gravity is not the force that caused the injury, because it occurs when the skin and underlying tissues are compressed between a bony prominence and an external surface, such as when the client lies on his back. Pressure or gravity can impair blood flow and oxygen delivery to the skin, resulting in tissue damage and ulceration.
Choice C reason: Chemical or pressure is not the force that caused the injury, because it occurs when the skin is exposed to a substance that causes irritation, inflammation, or corrosion, such as when the client has a wound dressing that contains an antiseptic or a topical agent. Chemical or pressure can damage the skin barrier and increase the risk of infection and delayed wound healing.
Choice D reason: Twisting and bending is not the force that caused the injury, because it occurs when the skin and underlying tissues are stretched or distorted, such as when the client twists his ankle or bends his knee. Twisting and bending can cause sprains, strains, or tears of the ligaments, tendons, or muscles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Creating a susceptible host is not a way to break the chain of infection, but rather a way to facilitate it. A susceptible host is someone who is vulnerable to infection due to factors such as age, immunocompromised status, or chronic diseases.
Choice B reason: Maintaining the integrity of a portal of entry is a way to break the chain of infection, because it prevents the entry of microorganisms into the body. A portal of entry is any place where microorganisms can enter the body, such as the skin, mucous membranes, or respiratory tract. By reducing skin breakdown, the nurse is protecting the skin from becoming a portal of entry for infection.
Choice C reason: Creating a reservoir to decrease the risk of infection is a contradiction, because a reservoir is a place where microorganisms can multiply and survive, such as a human, animal, or environment. A reservoir increases the risk of infection, not decreases it.
Choice D reason: Sterilizing the area to reduce the reservoir risk is a way to break the chain of infection, but it is not related to reducing skin breakdown. Sterilizing the area means killing or removing all microorganisms from a surface or object, such as a surgical instrument or a wound dressing. This can reduce the reservoir risk, but it does not affect the integrity of the skin as a portal of entry.
Correct Answer is D
Explanation
Choice A reason: Use gentle brushing and flossing techniques for clients with fragile mucosa is an important nursing intervention, but it is not the priority. Gentle brushing and flossing can help prevent plaque, gingivitis, and infection in the oral cavity, especially for clients with fragile mucosa due to dehydration, medication, or radiation. However, this intervention is not as urgent as having a suction apparatus ready at the bedside.
Choice B reason: Handle dentures with care is an important nursing intervention, but it is not the priority. Handling dentures with care can prevent damage, loss, or misplacement of the dentures, which can affect the client's comfort, appearance, and nutrition. However, this intervention is not as urgent as having a suction apparatus ready at the bedside.
Choice C reason: Position the client on one side with the head turned towards you is an important nursing intervention, but it is not the priority. Positioning the client on one side with the head turned towards you can facilitate the access and visibility of the oral cavity, as well as prevent the aspiration of saliva, blood, or debris. However, this intervention is not as effective as having a suction apparatus ready at the bedside.
Choice D reason: Have a suction apparatus ready at the bedside is the priority nursing intervention, because it can prevent the aspiration of saliva, blood, or debris, which can cause choking, pneumonia, or respiratory distress. Having a suction apparatus ready at the bedside can allow the nurse to quickly and safely remove any secretions or foreign materials from the oral cavity or the airway of the unconscious client.
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