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 A

Explanation

Choice A rationale

The nurse should check the equipment first when an ICP reading of 0 mm Hg is noted, as this may indicate equipment malfunction. An accurate ICP reading is critical for assessing and managing intracranial pressure to ensure the client's safety.

Choice B rationale

Continuing the assessment without checking the equipment may lead to incorrect conclusions based on a potentially faulty reading. It’s crucial to ensure the accuracy of the equipment before proceeding.

Choice C rationale

Documenting the reading as an effective treatment outcome without verifying its accuracy can be dangerous. An ICP reading of 0 mm Hg is unusual and warrants equipment verification.

Choice D rationale

Contacting the health care provider to review the care plan is premature until the equipment has been checked to rule out a false reading, ensuring the nurse provides accurate information.

A. Stupor. B. Somnolence. C. Normal. D. Deep coma.

Correct Answer is D

Explanation

Choice A rationale

Stupor refers to a state of near-unconsciousness or insensibility, where the patient can be briefly aroused by vigorous or repeated stimuli.

Choice B rationale

Somnolence refers to a state of strong desire for sleep or sleeping for unusually long periods (drowsiness), but it is not as severe as stupor or coma.

Choice C rationale

Normal consciousness means the patient is awake, alert, and responsive to their environment with no neurological deficits.

Choice D rationale

A score of 6 on the Glasgow Coma Scale indicates deep coma, where the patient has minimal to no response to stimuli, indicating severe brain injury.

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Pressure ulcers are caused by:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Correct Answer is A

Explanation

The critical care nurse is giving end-of-shift report on a client. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?

Correct Answer is D

Explanation

Which of the following is the first-line medication that would be used to treat and prevent osteoporosis?

Pressure ulcers are caused by:

The nurse is assessing a client with toxic epidermal necrolysis (TEN). What assessment data would indicate that the client may be progressing to keratoconjunctivitis? Select all that apply.

What should the nurse suspect when hourly assessment of urine output on a client post craniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours?

The nurse is assessing the fingernails of a client at the clinic. The nurse observes pitting on the surface of the nail. What disorder is this finding indicative of?

The nurse is preparing a client for a neurological examination by the health care provider and explains tests the health care provider will be doing, including the Romberg test. The client asks the purpose of this particular test. The correct reply by the nurse is which of the following?

When learning about the nervous system, students learn that which nervous system regulates the expenditure of energy?

During the skin assessment of a client, the nurse observes a skin lesion that is elevated, round, and filled with serum. Identify the type of lesion.