Which factor contributes to the formation of a pressure injury when a patient’s body slides downward to the foot of the bed?
Shearing force.
Acceleration.
Momentum.
Applied force.
The Correct Answer is A
Choice A rationale:
Shearing force is the primary factor that contributes to the formation of pressure injuries when a patient's body slides downward. It occurs when two surfaces move in opposite directions, causing stress and strain on the tissues between them.
Compression of Tissues: When the patient's body slides downward, the skin and underlying tissues are compressed between the bony prominences (such as the sacrum or heels) and the surface of the bed. This compression restricts blood flow to the area, depriving the tissues of oxygen and nutrients.
Tissue Stretching and Tearing: As the body slides, the skin and underlying tissues are also stretched and pulled in opposite directions. This shearing force disrupts the normal alignment of cells and tissues, leading to microscopic tears and damage.
Impaired Blood Flow: Shearing force further compromises blood flow by stretching and compressing blood vessels. This reduces the delivery of oxygen and nutrients to the tissues, while also hindering the removal of waste products.
Tissue Damage and Necrosis: The combination of compression, stretching, and impaired blood flow leads to cell death and tissue necrosis. This is the hallmark of pressure injuries, which can range from superficial blisters to deep ulcers that extend into muscle and bone.
Factors that Increase Shearing Force: Certain factors can increase the risk of shearing force and pressure injury development, including:
Increased moisture (from sweat or incontinence) Decreased mobility
Poor skin integrity
Malnutrition
Friction from bedsheets
In conclusion, shearing force is the main factor that contributes to pressure injury formation when a patient's body slides downward. It disrupts blood flow, damages tissues, and can lead to significant wounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Employee Assistance Programs (EAPs): These programs focus on providing confidential counseling and support services to employees for personal and work-related issues, such as mental health, substance abuse, stress management, and family concerns. They do not play a role in determining nursing training requirements for intravenous line initiation.
Choice C rationale:
The MedWatch program: This is a voluntary reporting system for healthcare professionals and consumers to report adverse events and medication errors to the FDA. It's crucial for monitoring drug safety but does not establish training standards for nurses.
Choice D rationale:
The US Food and Drug Administration (FDA): This federal agency regulates food, drugs, medical devices, and cosmetics to ensure their safety and efficacy. While it sets standards for drug approval and labeling, it does not directly determine specific nursing training requirements.
Choice B rationale:
State Nurse Practice Acts: These laws, enacted by each state's legislature, define the scope of nursing practice, including the skills and tasks that nurses are legally authorized to perform. Intravenous line initiation is a skill that falls within the scope of nursing practice, and the specific training requirements for this skill are typically outlined in each state's Nurse Practice Act.
Key points:
State Nurse Practice Acts are the primary legal authority governing nursing practice within each state, including the necessary training for nurses to perform specific skills.
EAPs, MedWatch, and the FDA play important roles in healthcare but do not determine nursing training requirements
Nurses must be aware of the Nurse Practice Act in their state to ensure they are practicing within the legal scope of their profession and have received the required training for the skills they perform.
Correct Answer is B
Explanation
Choice A rationale:
A lactose-free diet does not contraindicate acupuncture therapy. Lactose intolerance is a digestive condition that does not affect blood clotting or the ability to receive acupuncture safely.
Acupuncture needles are very fine and do not typically cause bleeding. Even if minor bleeding occurs, it is not a concern for individuals without bleeding disorders.
Therefore, a lactose-free diet does not pose a risk for acupuncture.
Choice B rationale:
Thrombocytopenia is a condition characterized by a low platelet count. Platelets are essential for blood clotting. Acupuncture involves the insertion of needles into the skin. This can cause minor bleeding, even when performed correctly.
In individuals with thrombocytopenia, even minor bleeding can be difficult to control and may lead to excessive bruising or hematoma formation.
Therefore, thrombocytopenia is a contraindication to acupuncture therapy due to the increased risk of bleeding complications.
Choice C rationale:
Herniated lumbar disks are a common condition that can cause back pain. Acupuncture is often used to treat back pain, including pain caused by herniated disks.
Studies have shown that acupuncture can be effective in reducing pain and improving function in patients with herniated disks.
Therefore, the presence of herniated lumbar disks does not contraindicate acupuncture therapy.
Choice D rationale:
Latex and strawberry allergies are not contraindications to acupuncture therapy. Acupuncture needles are typically made of stainless steel, which does not contain latex.
Additionally, acupuncture does not involve the use of strawberries or any other substances that are common allergens. Therefore, latex and strawberry allergies do not pose a risk for acupuncture.
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