A client has been immobile for an extended period due to a spinal cord injury. The nurse is assessing the client for the risk of developing pressure ulcers.
Which statement regarding the client's immobility and pressure ulcer risk is accurate?
"Immobilization has no impact on the risk of pressure ulcer development.".
"The client's sensory deficits will prevent them from developing pressure ulcers.".
"Prolonged immobility increases the risk of pressure ulcers due to decreased tissue perfusion.".
"The client's spinal cord injury will lead to improved blood flow and oxygenation in the skin.".
The Correct Answer is C
Choice A rationale:
"Immobilization has no impact on the risk of pressure ulcer development." This statement is not accurate.
Immobilization significantly increases the risk of pressure ulcer development.
Prolonged pressure on the skin and tissues due to immobility can lead to tissue ischemia and pressure ulcer formation.
Choice B rationale:
"The client's sensory deficits will prevent them from developing pressure ulcers." Sensory deficits, such as those resulting from a spinal cord injury, can actually increase the risk of pressure ulcers.
Patients with sensory deficits may not feel discomfort or pain, making them less likely to reposition themselves and relieve pressure on vulnerable areas.
Choice C rationale:
"Prolonged immobility increases the risk of pressure ulcers due to decreased tissue perfusion." This statement is accurate.
Prolonged immobility reduces tissue perfusion (blood flow) to areas under pressure, increasing the risk of pressure ulcer development.
Choice D rationale:
"The client's spinal cord injury will lead to improved blood flow and oxygenation in the skin." This statement is not accurate.
A spinal cord injury does not lead to improved blood flow and oxygenation in the skin.
In fact, it can contribute to impaired mobility and sensory deficits, which increase the risk of pressure ulcers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
The wound's warmth to the touch is not a primary factor to consider when selecting a dressing for a pressure ulcer.
The choice of dressing should primarily be based on the wound's characteristics, such as its depth, exudate level, and tissue involvement.
Choice B rationale:
The presence of a foul odor from the wound is an important factor to consider when selecting a dressing.
Malodorous wounds may indicate infection or necrotic tissue, and appropriate wound dressings can help manage odor and promote healing.
Choice C rationale:
The extent of tissue damage, including muscle and bone involvement, is a critical factor in choosing an appropriate dressing for a pressure ulcer.
Dressings should be selected based on the depth of the wound and the extent of tissue damage to support healing and prevent complications.
Choice D rationale:
The patient's mobility and pressure on vulnerable areas are essential considerations when selecting a dressing.
Dressings should help offload pressure from vulnerable areas and promote mobility while providing optimal wound care.
The choice of dressing should support the overall management of the patient's condition.
Correct Answer is A
Explanation
Choice A rationale:
The nurse is likely to observe warmth around the pressure ulcer site with intact skin.
This is a characteristic clinical manifestation of a stage 1 pressure ulcer.
In stage 1 pressure ulcers, there is non-blanchable erythema (redness) of the skin due to localized inflammation, and the area may feel warm to the touch.
However, the skin is still intact, and there are no open wounds or pus.
Choice B rationale:
This choice is incorrect because the patient described in the question has intact skin, and there is no mention of an open wound with pus.
Pus is typically associated with wound infection, which is not a feature of stage 1 pressure ulcers.
Choice C rationale:
The patient reporting a sharp pain in the affected area is not consistent with the characteristics of a stage 1 pressure ulcer.
Stage 1 pressure ulcers are typically not associated with pain because they only involve the superficial layers of the skin, and the underlying tissues are not affected.
Choice D rationale:
Swelling around the wound is not a typical clinical manifestation of a stage 1 pressure ulcer.
In stage 1, the skin may appear red and feel warm to the touch due to inflammation, but there is no mention of swelling in the question.
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