The nurse is caring for an immobilized client who is at risk for breakdown in skin integrity. Which pathophysiological process should the nurse note early in the development of a pressure injury?

Epidermal fragility and skin excoriation with serous drainage.

Hypodermal fluid accumulation and blister formation.

Necrotic tissue, purulent exudate and eschar formation.

Ischemic inflammatory response marked by erythemic skin.

Answer and Explanation

The Correct Answer is D

Pressure injuries, also known as pressure ulcers or bedsores, result from prolonged pressure on the skin, leading to tissue ischemia and damage. Early recognition of the pathophysiological processes involved in pressure injury development is crucial for prevention and timely intervention. Here's why option D is the correct choice:

A) Epidermal fragility and skin excoriation with serous drainage:

This description more closely aligns with the characteristics of a superficial wound or abrasion rather than the early stages of a pressure injury. In pressure injuries, epidermal breakdown may occur later in the process, after prolonged pressure and tissue ischemia.

B) Hypodermal fluid accumulation and blister formation:

While fluid accumulation and blister formation can occur in some types of wounds, such as friction blisters or burns, they are not typically characteristic of the early stages of pressure injury development. Pressure injuries primarily involve tissue ischemia and damage due to pressure and shear forces.

C) Necrotic tissue, purulent exudate, and eschar formation:

This description is more indicative of advanced or severe pressure injuries rather than the early stages. Necrotic tissue, purulent exudate, and eschar formation typically occur in pressure injuries that have progressed to deeper tissue involvement and infection.

D) Ischemic inflammatory response marked by erythemic skin:

Correct. In the early stages of pressure injury development, the affected area may exhibit signs of tissue ischemia and inflammation, which can manifest as erythema (redness) of the skin. This erythema is a result of the body's inflammatory response to tissue damage caused by pressure and may indicate the need for intervention to relieve pressure and prevent further injury.

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Correct Answer is C

Explanation

A) Increased preload that results in generalized peripheral edema:

This statement is incorrect. Decreased blood volume due to hemorrhage leads to decreased preload, not increased preload. Generalized peripheral edema is more commonly associated with conditions such as heart failure or kidney disease, where fluid retention leads to increased preload.

B) The lowered blood pressure results in a reduction of the heart rate:

While it's true that a decrease in blood pressure can trigger compensatory mechanisms such as an increase in heart rate (tachycardia), the specific response mentioned in this option is not entirely accurate. The primary compensatory response to hemorrhage-induced hypotension is typically an increase in heart rate, not a reduction.

C) Decreased preload that can lead to decreased cardiac output:

Correct. With decreased blood volume (preload), there is less blood returning to the heart during diastole. This leads to decreased ventricular filling and subsequently decreased stroke volume and cardiac output. Decreased cardiac output can contribute to hypotension and inadequate tissue perfusion.

D) Increased peripheral resistance resulting from poor renal perfusion:

While poor renal perfusion can trigger mechanisms to increase peripheral resistance (such as activation of the renin-angiotensin-aldosterone system), this option does not directly address the primary effect of decreased preload on cardiac output. Increased peripheral resistance alone does not adequately compensate for decreased preload to maintain cardiac output.

A. 40 to 60. B. 20 to 40. C. 60 to 80. D. 80 to 100.

Correct Answer is A

Explanation

The atrioventricular (AV) node is an essential component of the cardiac conduction system responsible for transmitting electrical impulses from the atria to the ventricles. The inherent rate of the AV node refers to its intrinsic ability to generate electrical impulses in the absence of external influences.

Here's a breakdown of each option:

A) 40 to 60:

Correct. The inherent rate of the AV node is typically 40 to 60 beats per minute (bpm). This rate is slower than that of the sinoatrial (SA) node, which has an inherent rate of 60 to 100 bpm. The AV node acts as a backup pacemaker, ensuring that the ventricles receive electrical impulses even if the SA node fails to function properly.

B) 20 to 40:

This range is not consistent with the typical inherent rate of the AV node. A rate of 20 to 40 bpm would be unusually slow and could indicate significant conduction system abnormalities rather than the normal functioning of the AV node.

C) 60 to 80:

This range is more characteristic of the inherent rate of the SA node rather than the AV node. The SA node is the primary pacemaker of the heart, and its inherent rate is typically 60 to 100 bpm.

D) 80 to 100:

Similar to option C, this range is more consistent with the inherent rate of the SA node rather than the AV node. The SA node typically has a faster intrinsic rate compared to the AV node.

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The nurse is caring for an immobilized client who is at risk for breakdown in skin integrity. Which pathophysiological process should the nurse note early in the development of a pressure injury?

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