What are the causes of a pressure ulcer? (Select all that apply.)

Ischemia

Immobility

Poor nutrition

Moisture

Adequate perfusion

Answer and Explanation

Correct Answer : A,B,C,D

Choice A reason: Ischemia is a cause of a pressure ulcer, because it means reduced blood flow to the tissues, which can lead to tissue hypoxia, necrosis, and ulceration. Ischemia can result from factors such as compression, friction, shear, or vascular disease.

Choice B reason: Immobility is a cause of a pressure ulcer, because it means prolonged pressure on the bony prominences, which can impair blood flow and cause ischemia, tissue damage, and ulceration. Immobility can result from factors such as paralysis, injury, illness, or sedation.

Choice C reason: Poor nutrition is a cause of a pressure ulcer, because it means inadequate intake or absorption of nutrients, such as protein, calories, vitamins, and minerals, which are essential for tissue repair and wound healing. Poor nutrition can result from factors such as anorexia, malabsorption, or poverty.

Choice D reason: Moisture is a cause of a pressure ulcer, because it means excessive wetness or dampness of the skin, which can weaken the skin barrier, increase the risk of infection, and delay wound healing. Moisture can result from factors such as incontinence, perspiration, or wound drainage.

Choice E reason: Adequate perfusion is not a cause of a pressure ulcer, but rather a protective factor. Adequate perfusion means sufficient blood flow to the tissues, which can prevent ischemia, tissue damage, and ulceration. Adequate perfusion can be promoted by factors such as regular repositioning, pressure relief, and exercise.

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Correct Answer is D

Explanation

Choice A reason: Use gentle brushing and flossing techniques for clients with fragile mucosa is an important nursing intervention, but it is not the priority. Gentle brushing and flossing can help prevent plaque, gingivitis, and infection in the oral cavity, especially for clients with fragile mucosa due to dehydration, medication, or radiation. However, this intervention is not as urgent as having a suction apparatus ready at the bedside.

Choice B reason: Handle dentures with care is an important nursing intervention, but it is not the priority. Handling dentures with care can prevent damage, loss, or misplacement of the dentures, which can affect the client's comfort, appearance, and nutrition. However, this intervention is not as urgent as having a suction apparatus ready at the bedside.

Choice C reason: Position the client on one side with the head turned towards you is an important nursing intervention, but it is not the priority. Positioning the client on one side with the head turned towards you can facilitate the access and visibility of the oral cavity, as well as prevent the aspiration of saliva, blood, or debris. However, this intervention is not as effective as having a suction apparatus ready at the bedside.

Choice D reason: Have a suction apparatus ready at the bedside is the priority nursing intervention, because it can prevent the aspiration of saliva, blood, or debris, which can cause choking, pneumonia, or respiratory distress. Having a suction apparatus ready at the bedside can allow the nurse to quickly and safely remove any secretions or foreign materials from the oral cavity or the airway of the unconscious client.

A. Blanching B. Cellulitis C. Tunneling D. Eschar

Correct Answer is D

Explanation

Choice A reason: Blanching is not the term for black and necrotic tissue. Blanching is the temporary whitening of the skin when pressure is applied. It indicates that the blood flow is intact and the tissue is healthy.

Choice B reason: Cellulitis is not the term for black and necrotic tissue. Cellulitis is a bacterial infection of the skin and subcutaneous tissue. It causes redness, swelling, warmth, and pain in the affected area.

Choice C reason: Tunneling is not the term for black and necrotic tissue. Tunneling is a narrow channel or pathway that extends from the wound into the surrounding tissue. It indicates a deeper and more complex wound.

Choice D reason: Eschar is the term for black and necrotic tissue. Eschar is a thick, dry, and hard crust that forms over a wound. It indicates a severe tissue damage and impaired healing.

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What are the causes of a pressure ulcer? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?

Correct Answer is D

Explanation

The nurse assesses a deep wound. The area is covered by black and necrotic tissue. What term would the nurse use when documenting this wound?

Correct Answer is D

Explanation

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