A nurse is assessing a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?
Sensory loss.
Poor circulation.
Muscle weakness.
Incontinence.
The Correct Answer is B
Choice A reason: Sensory loss increases pressure injury risk by reducing pain perception, preventing repositioning to relieve pressure. However, it is not the primary factor, as poor circulation directly impairs tissue oxygenation and nutrient delivery, making skin more susceptible to breakdown under prolonged pressure in immobile patients.
Choice B reason: Poor circulation, often from vascular disease or immobility, reduces blood flow to tissues, limiting oxygen and nutrient delivery. This impairs skin integrity, increasing susceptibility to pressure injuries. Prolonged pressure compresses capillaries, and poor circulation exacerbates ischemia, leading to tissue necrosis, a key factor in pressure ulcer formation.
Choice C reason: Muscle weakness contributes to immobility, increasing pressure injury risk by limiting repositioning. However, it is secondary to poor circulation, which directly causes tissue hypoxia and necrosis under pressure. Weak muscles reduce mobility but do not impair perfusion as directly as circulatory deficits do.
Choice D reason: Incontinence increases pressure injury risk by causing skin maceration, weakening the epidermal barrier. While significant, it is less critical than poor circulation, which directly reduces tissue oxygenation and healing capacity, making skin more vulnerable to breakdown from pressure in immobile clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Sleep enhances concentration by restoring prefrontal cortex function, improving attention and executive function. Decreased ability to concentrate results from sleep deprivation, which disrupts neural synchronization and reduces acetylcholine levels, impairing cognitive processing, not a direct outcome of normal sleep physiology.
Choice B reason: Sleep strengthens the immune system by promoting T-cell proliferation and cytokine release (e.g., IL-2), enhancing pathogen defense. A weakened immune system results from sleep deprivation, which elevates cortisol, suppressing immune function, contrary to the restorative effects of sleep on immune homeostasis.
Choice C reason: Basal metabolic rate decreases during sleep, as the body enters a low-energy state, reducing heart rate and oxygen consumption. Non-REM sleep lowers metabolic demand, conserving energy, while an increase in metabolism occurs during wakefulness or REM sleep, not as a general sleep outcome.
Choice D reason: Sleep facilitates memory consolidation, transferring short-term memories to long-term storage via hippocampal-neocortical interactions. Slow-wave sleep and REM sleep enhance synaptic plasticity, strengthening neural connections through protein synthesis and LTP (long-term potentiation), critical for learning and memory retention in the brain.
Correct Answer is B
Explanation
Choice A reason: Taking sucralfate with antacids reduces its efficacy, as antacids increase gastric pH, interfering with sucralfate’s ability to form a protective gel over ulcers. Sucralfate requires an acidic environment to bind to ulcerated mucosa, and antacids disrupt this, decreasing mucosal protection and delaying healing.
Choice B reason: Sucralfate is taken 1 hour before meals to ensure an acidic gastric environment, allowing it to form a protective barrier over ulcers. This timing maximizes mucosal adhesion, shielding against acid and pepsin, promoting healing. Food buffers stomach acid, reducing sucralfate’s effectiveness if taken concurrently.
Choice C reason: Taking sucralfate with food reduces its effectiveness, as food increases gastric pH and physically interferes with sucralfate’s binding to ulcer sites. This diminishes the formation of the protective gel, allowing acid and pepsin to irritate ulcers, delaying healing and symptom relief.
Choice D reason: Taking sucralfate only at bedtime limits its therapeutic effect, as it needs multiple daily doses (e.g., four times daily) to maintain consistent mucosal protection. Bedtime dosing alone fails to shield ulcers during daytime acid exposure, reducing efficacy in managing peptic ulcer disease symptoms.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.