Which of the following causes skin breakdown?
Incontinence
Altered level of consciousness
Immobility
All of the above
The Correct Answer is D
Choice A: Incontinence is a cause of skin breakdown, as it can expose the skin to moisture, bacteria, and chemicals that can irritate and damage the skin.
Choice B: Altered level of consciousness is a cause of skin breakdown, as it can impair the patient's ability to sense and report pain, discomfort, or pressure on the skin.
Choice C: Immobility is a cause of skin breakdown, as it can reduce the blood flow and oxygen to the skin and increase the pressure on bony prominences.
Choice D: All of the above is correct, as all of these factors can contribute to skin breakdown.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Head of bed 45 degrees is not enough to prevent aspiration or choking, as the patient may still have difficulty swallowing and clearing their airway.
Choice B: Patient should be on a regular diet to rebuild their swallowing ability is not correct, as the patient may need a modified diet depending on their level of dysphagia or swallowing impairment. A regular diet may pose a risk of aspiration or choking.
Choice C: Have patient sit upright 90 degrees in bed or chair is correct, as this position helps the patient align their head and neck and use gravity to facilitate swallowing and prevent aspiration.
Choice D: All of the above is not correct, as only choice C is appropriate for assisting a stroke patient with feeding.
Correct Answer is D
Explanation
Choice A: Return to hospital immediately if patient is having severe headache or vomiting is correct because it can indicate increased intracranial pressure, bleeding, swelling, or infection in the brain. These are serious complications that can cause permanent damage or death. The patient and family should seek medical atention as soon as possible and not wait for other symptoms to appear.
Choice B: Return to hospital immediately for changes in level of consciousness is correct because it can also indicate worsening brain injury or complications from a head injury. Changes in level of consciousness can include confusion, drowsiness, agitation, or loss of awareness. The patient and family should monitor the patient's mental status and alertness and report any changes to the doctor.
Choice C: Call ambulance if unable to arouse patient is correct because it can mean that the patient has lost consciousness or is in a coma. This is a medical emergency that requires immediate intervention and resuscitation. The patient and family should not atempt to move or transport the patient by themselves but call for professional help.
Choice D: All of the above are correct because they are important instructions for the patient and family to follow when discharging patient home following a head injury. They can help prevent further harm or complications and ensure prompt treatment and recovery. The nurse should educate the patient and family about these instructions and provide them with writen information and contact numbers.
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