Which is not a risk factor for pressure injuries?
Limited ability to reposition
Requires stand-by assistance for ADLs
Poor nutritional state
Presence of moisture due to incontinence, wound drainage, or perspiration
The Correct Answer is B
Choice A reason: Limited ability to reposition is a major risk factor for pressure injuries, as immobility increases pressure on bony prominences, reducing blood flow and causing tissue ischemia. This leads to skin breakdown, particularly in bedridden patients, making it a critical factor in pressure ulcer development.
Choice B reason: Requiring stand-by assistance for activities of daily living (ADLs) indicates some mobility, as the patient can perform tasks with supervision. This does not inherently increase pressure injury risk, unlike immobility or moisture, making it the least relevant risk factor among the choices.
Choice C reason: Poor nutritional state is a risk factor for pressure injuries, as malnutrition impairs skin integrity and wound healing. Deficiencies in protein or vitamins reduce tissue resilience, increasing susceptibility to pressure-induced damage, particularly in elderly or debilitated patients.
Choice D reason: Moisture from incontinence, wound drainage, or perspiration softens skin, increasing friction and shear forces, which heighten pressure injury risk. It compromises skin barrier function, promoting maceration and ulceration, making it a significant contributor to pressure ulcer formation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A stethoscope assesses heart sounds, detecting murmurs or irregular beats, but does not measure electrical conduction. It provides auditory data on valve function, not heart rate or rhythm via electrical activity. Electrocardiograms are required for detailed analysis of cardiac electrical patterns, making this choice incorrect.
Choice B reason: A blood pressure cuff measures arterial pressure, reflecting cardiovascular workload, but not electrical conduction. It provides systolic and diastolic values, not heart rhythm or rate data. Electrical activity assessment requires tools like electrocardiograms, rendering this choice irrelevant for the described diagnostic purpose.
Choice C reason: An electrocardiogram (ECG) records the heart’s electrical activity, mapping conduction pathways to assess heart rate and rhythm. It detects arrhythmias, ischemia, or conduction delays by analyzing waveforms like P, QRS, and T, making it the precise tool for evaluating cardiac electrical function, as required by the question.
Choice D reason: Doppler ultrasound evaluates blood flow velocity, used in vascular or fetal assessments, but does not measure cardiac electrical conduction. It lacks the capability to assess heart rate or rhythm through electrical signals, unlike an electrocardiogram, making it an incorrect choice for this diagnostic purpose.
Correct Answer is A
Explanation
Choice A reason: Stage 4 pressure injury involves full-thickness tissue loss with exposed muscle, bone, or tendon, as described with a deep depression and visible bone. This severe stage requires aggressive interventions like debridement or surgery. Accurate staging ensures proper wound care, preventing infection and promoting healing in advanced pressure injuries.
Choice B reason: Stage 3 involves full-thickness loss to subcutaneous tissue, not muscle or bone, unlike the described injury with visible bone (stage 4). Misstaging as 3 underestimates severity, risking inadequate treatments like simple dressings, delaying surgical intervention or infection control critical for deep pressure injuries with bone exposure.
Choice C reason: Stage 1 is intact skin with erythema, not a deep lesion with bone exposure, which is stage 4. Misstaging as 1 grossly underestimates severity, neglecting urgent needs like debridement or antibiotics, risking infection, sepsis, or further tissue loss in severe pressure injuries requiring advanced wound management.
Choice D reason: Stage 2 involves partial-thickness loss with a shallow wound, not deep muscle or bone exposure, as in stage 4. Misstaging as 2 risks inadequate care, like topical treatments instead of surgical intervention, delaying healing and increasing complications like osteomyelitis in severe pressure injuries with visible bone.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
