A client with diabetes is receiving care from a nurse. The client is at risk of developing pressure ulcers due to their medical condition.

What statement accurately identifies a risk factor for pressure ulcers in this client?

Choice A rationale:

Consulting with the healthcare team to address underlying medical conditions (Choice A) is the most appropriate nursing action for a client with a pressure ulcer and signs of infection.

Pressure ulcers can develop or worsen due to underlying medical conditions such as diabetes, vascular disease, or immunosuppression.

Addressing these underlying conditions is essential for effective wound management and preventing further complications.

Choice B rationale:

Encouraging frequent position changes and mobility exercises (Choice B) is a valuable intervention to prevent pressure ulcers, but in a client with an existing pressure ulcer and signs of infection, addressing the infection and underlying medical conditions take precedence.

Choice C rationale:

Using specialized mattresses to offload pressure (Choice C) is an important part of pressure ulcer prevention and management, but it may not be the most immediate action needed for a client with signs of infection.

Addressing infection and underlying medical conditions (Choice A) should be the priority.

Choice D rationale:

Providing education on proper wound care and prevention strategies (Choice D) is an essential nursing action but may not be the most immediate priority for a client with an active infection.

Managing the infection and addressing underlying medical conditions (Choice A) should come first.

Choice A rationale:

"Pressure ulcers occur due to excessive friction on the skin." This statement is not accurate.

While friction can contribute to the development of pressure ulcers, it is not the primary pathophysiological factor.

Pressure ulcers primarily result from tissue ischemia and hypoxia, as well as pressure on the skin and underlying tissues.

Choice B rationale:

"Damage to the skin and underlying tissues in pressure ulcers is primarily caused by a lack of proper hygiene." Hygiene is essential in preventing pressure ulcers, but it is not the primary cause of their development.

Pressure ulcers are mainly caused by sustained pressure on bony prominences, leading to reduced blood flow and oxygenation to the affected area.

Choice C rationale:

"Ischemia and tissue hypoxia play a significant role in the development of pressure ulcers." This statement is correct.

Ischemia (reduced blood flow) and tissue hypoxia (inadequate oxygen supply) are key pathophysiological factors in the development of pressure ulcers.

Prolonged pressure on the skin and tissues leads to compromised blood flow, tissue damage, and ultimately, pressure ulcer formation.

Choice D rationale:

"Pressure ulcers result from a hyperactive immune response in the affected area." This statement is not accurate.

Pressure ulcers are not primarily caused by a hyperactive immune response.

While inflammation may occur in response to tissue damage, it is not the root cause of pressure ulcers.