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

Choice A reason: Padding hard surfaces is a nursing intervention that decreases the risk of pressure injuries, because it reduces the pressure, shear, and friction on the skin and underlying tissues. Hard surfaces, such as bed rails, wheelchair arms, or footrests, can cause compression or irritation of the skin, especially over the bony prominences. Padding hard surfaces with foam, gel, or air cushions can provide protection and comfort for the client.

Choice B reason: Keeping head of bed (HOB) at or less than 30 degrees is a nursing intervention that decreases the risk of pressure injuries, because it prevents the sliding or shifting of the client in bed. Sliding or shifting can cause shear and friction on the skin, especially over the sacrum, coccyx, or heels. Keeping head of bed (HOB) at or less than 30 degrees can maintain the alignment and stability of the client in bed.

Choice C reason: Keeping head of bed (HOB) elevated to 75 degrees is not a nursing intervention that decreases the risk of pressure injuries, but rather one that increases the risk of pressure injuries. Elevating the head of bed (HOB) to 75 degrees can cause the client to slide or shift in bed, which can increase the shear and friction on the skin, as explained above. Elevating the head of bed (HOB) to 75 degrees can also increase the pressure on the sacrum, coccyx, or heels, which can impair the blood flow and oxygen delivery to the skin and tissues.

Choice D reason: Having client sit in wheelchair as much as possible is not a nursing intervention that decreases the risk of pressure injuries, but rather one that increases the risk of pressure injuries. Sitting in wheelchair as much as possible can cause prolonged pressure, shear, and friction on the skin and underlying tissues, especially over the ischial tuberosities, sacrum, coccyx, or heels. Sitting in wheelchair as much as possible can also reduce the mobility and activity of the client, which can affect the blood circulation and muscle tone.

Choice E reason: Placing pillows between bony surfaces is a nursing intervention that decreases the risk of pressure injuries, because it relieves the pressure, shear, and friction on the skin and underlying tissues. Bony surfaces, such as the ankles, knees, hips, or elbows, can cause compression or irritation of the skin, especially when they are in contact with each other or with the bed. Placing pillows between bony surfaces can provide cushioning and separation for the skin and tissues.

Choice A reason: This is the best intervention because it helps the nurse to understand the client's emotional, social, and practical needs and resources. A new diagnosis of HIV can be a devastating and overwhelming experience for the client, who may face stigma, discrimination, isolation, or rejection from others. The nurse should assess the client's support system, such as family, friends, or community groups, that can provide comfort, guidance, and assistance to the client. The nurse should also encourage the client to seek professional counseling, peer support, or other services as needed.

Choice B reason: This is not the best intervention because it may not respect the client's preferences, beliefs, or values. The nurse should not assume that the client wants or needs spiritual or religious support, unless the client expresses such a desire. The nurse should ask the client about their spiritual or religious beliefs and practices and provide appropriate referrals or resources as requested by the client. The nurse should also respect the client's right to privacy and confidentiality and not disclose the client's diagnosis to anyone without the client's consent.

Choice C reason: This is not the best intervention because it may not be the most urgent or appropriate topic to discuss with the client at this time. The nurse should not focus on the legal or ethical aspects of the client's diagnosis, but rather on the client's emotional and physical wellbeing. The nurse should explain the legal requirement to tell sex partners in a sensitive and respectful manner, but only after the client has accepted and understood their diagnosis and has expressed readiness to disclose their status to others. The nurse should also provide the client with information and resources on how to prevent the transmission of HIV and how to protect themselves and their partners.

Choice D reason: This is not the best intervention because it may not be the client's wish or choice. The nurse should not offer to tell the family for the client, unless the client asks for such help. The nurse should respect the client's autonomy and decisionmaking regarding whom to tell and when to tell about their diagnosis. The nurse should also support the client in preparing for the possible reactions and outcomes of disclosing their status to their family and others.