Pressure ulcers are caused by:

Necrosis.

Low capillary pressure.

Increased mobility.

Extrinsic factors.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Necrosis is tissue death resulting from prolonged pressure, often a consequence rather than the direct cause of pressure ulcers. The primary cause is sustained pressure impairing blood flow.

Choice B rationale

Low capillary pressure does not directly cause pressure ulcers. They result from sustained external pressure exceeding capillary perfusion pressure, leading to ischemia and tissue damage.

Choice C rationale

Increased mobility actually prevents pressure ulcers by reducing sustained pressure on any one area, enhancing blood flow and tissue health. Immobility is a significant risk factor, not increased mobility.

Choice D rationale

Extrinsic factors like sustained pressure, friction, shear, and moisture contribute directly to pressure ulcer development by compromising skin integrity and blood flow, leading to tissue ischemia and damage.

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Correct Answer is D

Explanation

Choice A rationale

Rigidity is characterized by a continuous resistance to passive movement in any direction and does not specifically occur during abrupt dorsiflexion of the foot.

Choice B rationale

Flaccidity refers to decreased muscle tone or limpness, which is the opposite of hyperactivity or spasticity, and would not be observed with abrupt dorsiflexion.

Choice C rationale

Ataxia involves uncoordinated or erratic movements and is related to cerebellar dysfunction. This is not specifically triggered by abrupt dorsiflexion of the foot.

Choice D rationale

Clonus is the correct term for rhythmic, involuntary contractions of a muscle that occur when it is suddenly stretched, such as with abrupt dorsiflexion of the foot. It is a sign of hyperactive reflexes and upper motor neuron lesions.

A. Position the client flat as directed. B. Leave the client to rest and do not perform any assessments. C. Provide caffeine-rich drinks to the client. D. Avoid administering analgesic agents to the client. E. Avoid administering analgesic agents to the client.

Correct Answer is A

Explanation

Choice A rationale

Positioning the client flat as directed is the priority intervention after a lumbar puncture to prevent cerebrospinal fluid (CSF) leakage, which can lead to a post-lumbar puncture headache. This position helps maintain normal CSF pressure and promotes sealing of the puncture site.

Choice B rationale

Leaving the client to rest without performing any assessments is not appropriate, as continuous monitoring is necessary to detect any complications such as bleeding or changes in neurological status. Regular assessments help ensure timely intervention if issues arise.

Choice C rationale

Providing caffeine-rich drinks is sometimes recommended to alleviate headaches caused by CSF leakage post-lumbar puncture. However, it is not the priority intervention immediately after the procedure, which focuses on positioning and monitoring.

Choice D rationale

Avoiding analgesic agents is incorrect. Pain management is an important aspect of care post-lumbar puncture, and appropriate analgesics should be administered as needed. The focus should be on positioning and monitoring, not withholding pain relief.

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Pressure ulcers are caused by:

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Naxlex Comprehensive Predictor Exams

Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed?

Correct Answer is D

Explanation

A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?

Correct Answer is A

Explanation

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