A nurse is caring for a client who has been bedridden for an extended period. The client has developed a pressure ulcer on their sacrum.
Which of the following statements best describes the pathophysiology of pressure ulcers?
"Pressure ulcers occur due to excessive friction on the skin.".
"Damage to the skin and underlying tissues in pressure ulcers is primarily caused by a lack of proper hygiene.".
"Ischemia and tissue hypoxia play a significant role in the development of pressure ulcers.".
"Pressure ulcers result from a hyperactive immune response in the affected area.".
The Correct Answer is C
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
"The client's advanced age is the primary factor affecting wound healing." While advanced age can affect wound healing, it is not the primary factor in this case.
The client's history of vascular disease is a more significant contributing factor.
Choice B rationale:
"The client's wound is not adequately protected from friction." Friction can impact wound healing, but in this case, vascular disease plays a more substantial role in impaired wound healing.
Choice C rationale:
"Vascular disease may lead to compromised blood flow and oxygenation in the affected area." This statement is correct.
Vascular disease can impair blood flow and oxygenation to tissues, significantly affecting wound healing.
Reduced blood flow deprives tissues of necessary nutrients and oxygen, leading to delayed healing.
Choice D rationale:
"The client's wound healing process is delayed due to a hyperactive immune response." A hyperactive immune response is not typically a primary factor in impaired wound healing associated with vascular disease.
The primary concern in vascular disease is compromised blood flow and tissue perfusion.
Correct Answer is C
Explanation
Choice A rationale:
Coldness to the touch is not a characteristic symptom of partial-thickness skin loss involving the epidermis and/or dermis.
This symptom is more indicative of compromised blood flow, such as in arterial insufficiency, and is not specific to pressure ulcers.
Choice B rationale:
Redness around the wound is a characteristic symptom of partial-thickness skin loss (stage 2 pressure ulcer).
This redness is due to localized inflammation and represents damage to the epidermis and/or dermis, but it does not involve muscle or deeper tissues.
Choice C rationale:
Tenderness when touching the wound is an expected symptom in partial-thickness skin loss involving the epidermis and/or dermis (stage 2 pressure ulcer).
The presence of tenderness is indicative of ongoing tissue damage and inflammation in the affected area.
Choice D rationale:
The statement, "My wound is deep, down to the muscle," suggests a full-thickness wound (stage 3 or 4 pressure ulcer) where muscle and deeper tissues are involved.
This statement does not align with the description provided in the question, which specifies partial-thickness skin loss.
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