Pressure ulcers are defined as an injury to the skin and/or underlying tissue resulting from pressure or in combination with shear, usually over a bony prominence. As a nurse, what do you know you must do to prevent pressure ulcers? (Select all that apply.)
Turn immobile clients every 2 hours off bony prominences.
Use lift or draw sheets to move clients in bed.
Keep the moist
Ensure that your client maintains a healthy nutritional status.
Apply pressure-relieving devices to vulnerable areas.
Correct Answer : A,B,D,E
Choice A reason: Turning immobile clients every 2 hours off bony prominences can reduce the pressure and friction that can cause skin breakdown and ulcer formation.
Choice B reason: Using lift or draw sheets to move clients in bed can prevent dragging or pulling the skin, which can cause shear and damage the underlying tissue.
Choice C reason: Keeping the skin moist is not a correct way to prevent pressure ulcers. Moisture can weaken the skin and make it more prone to injury. The skin should be kept dry and clean, and moisturized if needed.
Choice D reason: Ensuring that your client maintains a healthy nutritional status can promote wound healing and prevent infection. Adequate protein, calories, vitamins, and minerals are essential for skin integrity and tissue repair.
Choice E reason: Applying pressure-relieving devices to vulnerable areas can distribute the pressure and protect the skin from damage. Examples of pressure-relieving devices are foam pads, air mattresses, or cushions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This statement is incorrect because the zoster vaccine Shingrix can be given to individuals who have had a previous episode of Herpes Zoster (HZ), as long as they are not currently experiencing an acute outbreak. The vaccine can help prevent future recurrences of HZ, as well as reduce the risk of postherpetic neuralgia, a painful complication of HZ.
Choice B reason: This statement is correct because the zoster vaccine Shingrix is recommended for all individuals over age 50 that have no contraindications to the vaccine, such as a history of severe allergic reaction to any component of the vaccine, or a current severe immunodeficiency. The vaccine can help prevent HZ and its complications, which are more common and severe in older adults.
Choice C reason: This statement is incorrect because the zoster vaccine Shingrix can be given to individuals with a chronic cardiac or respiratory condition, as long as they are not immunocompromised. The vaccine is not a live vaccine, so it does not pose a risk of causing or worsening the underlying condition. The vaccine can help protect the individuals from HZ and its complications, which can exacerbate their condition or interfere with their treatment.
Choice D reason: This statement is incorrect because the zoster vaccine Shingrix does not always prevent an individual from developing Herpes Zoster. The vaccine has a high efficacy rate of about 90%, but it is not 100%. The vaccine can reduce the severity and duration of HZ, as well as the risk of postherpetic neuralgia, if it does occur..
Correct Answer is D
Explanation
Choice A reason: A detached retina is a serious condition that occurs when the retina, the light-sensitive layer of tissue at the back of the eye, separates from its underlying support tissue. It can cause vision loss or blindness if not treated promptly. However, it does not usually cause intense headaches or bloodshot eyes, but rather flashes of light, floaters, or a curtain-like shadow over the visual field.
Choice B reason: Macular degeneration is a common eye disorder that affects the macula, the central part of the retina that is responsible for sharp and detailed vision. It can cause blurred or distorted vision, especially in the center of the visual field. However, it does not usually cause intense headaches or bloodshot eyes, but rather difficulty reading, recognizing faces, or seeing colors.
Choice C reason: Cataracts are cloudy areas in the lens of the eye that can impair vision. They are usually related to aging, but can also be caused by other factors such as diabetes, trauma, or radiation. They can cause blurred or dim vision, sensitivity to light, or halos around lights. However, they do not usually cause intense headaches or bloodshot eyes, but rather gradual and painless vision loss.
Choice D reason: Angle-closure glaucoma is a type of glaucoma that occurs when the drainage angle of the eye becomes blocked, causing a sudden increase in the pressure inside the eye. It can damage the optic nerve and lead to permanent vision loss if not treated immediately. It can cause intense headaches, bloodshot eyes, blurred vision, nausea, vomiting, or seeing rainbow-colored rings around lights. It is a medical emergency that requires immediate attention.
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