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 A
Explanation
Choice A: Respiratory status is the first priority, as it can affect the oxygenation and perfusion of the brain and other vital organs. The nurse should assess the rate, rhythm, depth, and quality of breathing, as well as the use of accessory muscles, chest expansion, and lung sounds.
Choice B: Alertness is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to open their eyes spontaneously or in response to stimuli, as well as their orientation to person, place, time, and situation.
Choice C: Motor response is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to move their limbs voluntarily or in response to stimuli, as well as their muscle strength, tone, and coordination.
Choice D: Verbal response is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to speak clearly and coherently, as well as their content and appropriateness of speech.
Correct Answer is B
Explanation
Choice A: Pressure ulcer is not the most serious complication of a patient with altered level of consciousness, but rather a common and preventable complication that can cause skin breakdown, infection, and pain.
Choice B: Aspiration is the most serious complication of a patient with altered level of consciousness, as it can cause pneumonia, respiratory failure, and death.
Choice C: Contractures is not the most serious complication of a patient with altered level of consciousness, but rather a potential and reversible complication that can cause muscle stiffness, joint deformity, and reduced mobility.
Choice D: Deep vein thrombosis is not the most serious complication of a patient with altered level of consciousness, but rather a possible and treatable complication that can cause blood clots, swelling, and pain in the legs.
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