What are the causes of a pressure ulcer? (Select all that apply.)
Ischemia
Immobility
Poor nutrition
Moisture
Adequate perfusion
Correct Answer : A,B,C,D
Choice A reason: Ischemia is a cause of a pressure ulcer, because it means reduced blood flow to the tissues, which can lead to tissue hypoxia, necrosis, and ulceration. Ischemia can result from factors such as compression, friction, shear, or vascular disease.
Choice B reason: Immobility is a cause of a pressure ulcer, because it means prolonged pressure on the bony prominences, which can impair blood flow and cause ischemia, tissue damage, and ulceration. Immobility can result from factors such as paralysis, injury, illness, or sedation.
Choice C reason: Poor nutrition is a cause of a pressure ulcer, because it means inadequate intake or absorption of nutrients, such as protein, calories, vitamins, and minerals, which are essential for tissue repair and wound healing. Poor nutrition can result from factors such as anorexia, malabsorption, or poverty.
Choice D reason: Moisture is a cause of a pressure ulcer, because it means excessive wetness or dampness of the skin, which can weaken the skin barrier, increase the risk of infection, and delay wound healing. Moisture can result from factors such as incontinence, perspiration, or wound drainage.
Choice E reason: Adequate perfusion is not a cause of a pressure ulcer, but rather a protective factor. Adequate perfusion means sufficient blood flow to the tissues, which can prevent ischemia, tissue damage, and ulceration. Adequate perfusion can be promoted by factors such as regular repositioning, pressure relief, and exercise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Joint pain with swelling is the correct answer, because it is a common symptom of SLE. SLE is a chronic autoimmune disease that causes inflammation and damage to various organs and tissues, such as the skin, joints, kidneys, heart, and blood vessels. Joint pain with swelling is caused by the inflammation of the synovial membrane that lines the joints, which can lead to stiffness, reduced mobility, and deformity.
Choice B reason: Intense wrinkles is not the correct answer, because it is not a symptom of SLE. Intense wrinkles are a cosmetic issue that affects the appearance of the skin, not the function of the organs or tissues. Intense wrinkles are caused by the loss of collagen and elasticity in the skin, which can result from aging, sun exposure, smoking, or dehydration.
Choice C reason: Raynaud's phenomenon is not the correct answer, because it is not a symptom of SLE. Raynaud's phenomenon is a condition that affects the blood flow to the fingers and toes, not the joints or other organs. Raynaud's phenomenon is caused by the narrowing of the small arteries that supply blood to the extremities, which can result from cold, stress, or other factors.
Choice D reason: Tachycardia is not the correct answer, because it is not a symptom of SLE. Tachycardia is a condition that affects the heart rate, not the joints or other organs. Tachycardia is caused by the abnormal electrical activity of the heart, which can result from anxiety, fever, infection, or other causes.
Correct Answer is C
Explanation
Choice A reason: An event that can cause serious injury to a client that should never happen in a hospital is not the best description of a sentinel event, because it is too vague and broad. It does not specify the degree of injury or the nature of the event. It also implies that some events that cause serious injury are acceptable in a hospital, which is not true.
Choice B reason: Specific events that enable a hospital to maximize reimbursement is not a description of a sentinel event, but rather a description of quality indicators or performance measures. These are criteria that reflect the quality of care provided by a hospital and affect its payment from payers. They are not related to sentinel events, which are adverse events that require immediate investigation and response.
Choice C reason: An unexpected event involving death or serious physical or psychological injury is the best description of a sentinel event, because it captures the essence and severity of the event. According to the Joint Commission, a sentinel event is "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof" . Examples of sentinel events include wrongsite surgery, medication error, suicide, or abduction.
Choice D reason: Operating room event involving the use of unsafe equipment is not a description of a sentinel event, but rather an example of a potential sentinel event. It is not a general definition that applies to all sentinel events, but a specific scenario that may or may not result in death or serious injury. It also does not indicate the unexpectedness of the event, which is a key characteristic of a sentinel event.
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