Pressure ulcers are caused by:
Necrosis.
Low capillary pressure.
Increased mobility.
Extrinsic factors.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Necrosis is the death of body tissue and can result from various factors, including pressure ulcers, but it is not the direct cause of pressure ulcers.
Choice B rationale
Low capillary pressure is not a direct cause of pressure ulcers. Pressure ulcers are caused by prolonged pressure on the skin, leading to reduced blood flow and tissue damage.
Choice C rationale
Increased mobility is not a cause of pressure ulcers. In fact, decreased mobility or immobility is a significant risk factor for developing pressure ulcers.
Choice D rationale
Extrinsic factors, such as prolonged pressure, friction, and shear, are the primary causes of pressure ulcers. These factors lead to reduced blood flow, tissue ischemia, and ultimately, tissue damage.
Correct Answer is A
Explanation
Choice A rationale
Assessing the client's verbal response is the first step in evaluating their level of consciousness (LOC). It provides immediate information about their ability to communicate and follow commands.
Choice B rationale
Assessing the client's response to pain is a later step in the LOC assessment if the client does not respond to verbal stimuli. It helps determine the level of consciousness if the client is not verbally responsive.
Choice C rationale
Assessing the client's judgment is part of a cognitive assessment but is not the first action when assessing LOC. It evaluates higher brain functions, not the initial level of responsiveness.
Choice D rationale
Assessing the client's ability to follow complex commands is part of a cognitive assessment and provides information about higher brain function but is not the first step in LOC assessment.
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