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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Leukotrienes are inflammatory mediators derived from arachidonic acid metabolism, primarily produced by leukocytes (white blood cells) such as mast cells, eosinophils, and basophils. In the context of asthma, leukotrienes play a significant role in the pathophysiology of the disease by contributing to airway inflammation and bronchoconstriction. Here's a breakdown of their immune response:
A) Produce the sensation of itching:
Leukotrienes are not directly involved in producing the sensation of itching. Itching is often associated with histamine release rather than leukotrienes.
B) Tighten airway and produce mucous:
Correct. Leukotrienes are potent bronchoconstrictors that cause smooth muscle contraction in the airways, leading to narrowing (constriction) of the bronchioles. Additionally, they stimulate the secretion of mucus from goblet cells in the airway epithelium, contributing to airway obstruction and mucus production, which are characteristic features of asthma exacerbations.
C) Causes formation of bradykinin:
Bradykinin is a peptide mediator that is generated from the plasma protein kininogen and is involved in vasodilation, pain sensation, and inflammation. Leukotrienes are not directly responsible for the formation of bradykinin.
D) Serves as a receptor for antigen:
Leukotrienes do not serve as receptors for antigens. Instead, they are lipid mediators released in response to various stimuli, including allergens, infections, and irritants, and they act on specific receptors (e.g., leukotriene receptors) to exert their effects, such as bronchoconstriction and inflammation
Correct Answer is C
Explanation
Smoking is a well-established risk factor for lung cancer, and the pathophysiological process underlying this association involves the exposure of the lungs to carcinogenic agents present in tobacco smoke. Here's why option C is the correct choice:
A) Vasoconstrictive properties of nicotine reduce oxygenation and stimulate metabolism:
While nicotine is a primary addictive component of tobacco smoke and can lead to vasoconstriction, reduced oxygenation, and increased metabolism, these effects primarily contribute to cardiovascular diseases associated with smoking, such as coronary artery disease and stroke, rather than the development of lung cancer.
B) Drug addiction changes the neurochemical messages in the brain causing cravings:
This statement addresses the addictive nature of nicotine and its impact on neurochemistry, leading to cravings and dependence. While addiction is a significant aspect of tobacco use, it does not directly explain the pathophysiological process by which smoking causes lung cancer.
C) Carcinogenic agents in tobacco alter cellular cytology, morphology, and function of the lung:
Correct. Tobacco smoke contains numerous carcinogenic compounds, such as polycyclic aromatic hydrocarbons (PAHs), nitrosamines, and benzene, which can directly damage the DNA of lung cells. This DNA damage can lead to mutations and alterations in cellular cytology, morphology, and function, ultimately contributing to the development of lung cancer.
D) Risk for comorbidities increase incidence of chronic diseases and decrease longevity:
While smoking is associated with an increased risk of various comorbidities and chronic diseases, such as cardiovascular diseases, respiratory diseases, and certain cancers, this option does not specifically address the pathophysiological process of lung cancer development.
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