Immobility is a major risk for pressure ulcers. In caring for the patient who is immobilized, the nurse needs to be aware that:

Breaks in skin integrity are easy to heal

Preventing a pressure ulcer is more expensive than treating one

Immobilized patients can develop skin breakdown within 3 hours

Pressure ulcers are caused by a sudden influx of oxygen to the tissue

Answer and Explanation

The Correct Answer is C

A.   Breaks in skin integrity are not easy to heal, especially in immobilized patients, and can lead to serious complications.
B.   Preventing pressure ulcers is typically less expensive than treating them once they occur.
C.   Patients who are immobilized can indeed develop skin breakdown within a very short period, often within 2 to 3 hours of sustained pressure.
D.   Pressure ulcers are primarily caused by prolonged pressure, not by an influx of oxygen to the tissue.

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Correct Answer is B

Explanation

A. Venting can be therapeutic, but it doesn’t directly promote self-awareness.
B. Allowing open exploration of thoughts and feelings helps the patient reflect and gain insight into their emotions and behaviors.
C. Physically punching a pillow does not facilitate self-awareness and may encourage aggressive behavior.
D. Writing complaint letters might help express frustration but does not foster self-awareness.

A. Avoid using a transfer or gait belt around the patient's waist prior to transfer B. Assess for the need of a mechanical lift and help C. Not allow the patient to help in any way because resistance can lead to injury D. Ensure that the patient has stockings on his feet for transfer

Correct Answer is B

Explanation

A. Using a transfer or gait belt is generally recommended for safety during transfers.
B. Assessing for a mechanical lift is important, especially if the patient is unable to assist significantly; safety should always come first.
C. Allowing the patient to assist when able is important for their dignity and can make the transfer easier if done correctly.
D. While stockings can help with circulation, they are not the primary consideration for the transfer process.

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Immobility is a major risk for pressure ulcers. In caring for the patient who is immobilized, the nurse needs to be aware that:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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