Which factor contributes to the formation of a pressure injury when a patient’s body slides downward to the foot of the bed?
Shearing force.
Acceleration.
Momentum.
Applied force.
The Correct Answer is A
Choice A rationale:
Shearing force is the primary factor that contributes to the formation of pressure injuries when a patient's body slides downward. It occurs when two surfaces move in opposite directions, causing stress and strain on the tissues between them.
Compression of Tissues: When the patient's body slides downward, the skin and underlying tissues are compressed between the bony prominences (such as the sacrum or heels) and the surface of the bed. This compression restricts blood flow to the area, depriving the tissues of oxygen and nutrients.
Tissue Stretching and Tearing: As the body slides, the skin and underlying tissues are also stretched and pulled in opposite directions. This shearing force disrupts the normal alignment of cells and tissues, leading to microscopic tears and damage.
Impaired Blood Flow: Shearing force further compromises blood flow by stretching and compressing blood vessels. This reduces the delivery of oxygen and nutrients to the tissues, while also hindering the removal of waste products.
Tissue Damage and Necrosis: The combination of compression, stretching, and impaired blood flow leads to cell death and tissue necrosis. This is the hallmark of pressure injuries, which can range from superficial blisters to deep ulcers that extend into muscle and bone.
Factors that Increase Shearing Force: Certain factors can increase the risk of shearing force and pressure injury development, including:
Increased moisture (from sweat or incontinence) Decreased mobility
Poor skin integrity
Malnutrition
Friction from bedsheets
In conclusion, shearing force is the main factor that contributes to pressure injury formation when a patient's body slides downward. It disrupts blood flow, damages tissues, and can lead to significant wounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Side effect: A side effect is an effect of a drug that is secondary to the main intended effect. It is usually predictable and may be either beneficial or harmful. However, constipation is not a common or expected side effect of iron supplements. It is more likely to be an adverse reaction.
Choice B rationale:
Therapeutic effect: The therapeutic effect is the intended effect of a drug, the one that is desired to treat the condition. In this case, the therapeutic effect of the iron supplement would be to increase the patient's iron levels. Constipation is not the desired effect of the iron supplement, so it is not a therapeutic effect.
Choice C rationale:
Adverse reaction: An adverse reaction is an unwanted or harmful reaction to a drug that is not necessarily predictable. It can range from mild to severe. Constipation is a common adverse reaction to iron supplements. It is thought to be caused by the iron binding to undigested food in the intestines, making it harder to pass stool.
Choice D rationale:
Toxicity: Toxicity refers to a poisonous or harmful effect of a drug. It is usually caused by taking too much of a drug or by a drug interacting with another drug or substance. Constipation is not a sign of iron toxicity. Iron toxicity can cause symptoms such as nausea, vomiting, abdominal pain, and diarrhea.
Correct Answer is D
Explanation
Choice A rationale:
Incorrect because swallowing the tablet with water would lead to slower absorption and a delayed onset of action. Nitroglycerin is rapidly absorbed through the oral mucosa, and swallowing it would route it through the digestive system, where it would be absorbed more slowly and less effectively.
Swallowing the tablet could also increase the risk of side effects, such as headache and flushing, due to the larger amount of the drug that would be absorbed systemically.
Choice B rationale:
Incorrect because crushing the tablet and dissolving it in water would also delay its absorption. This method would require the tablet to dissolve in the water before it could be absorbed through the oral mucosa, which would slow down the onset of action.
Crushing the tablet could also damage the medication and make it less effective.
Choice C rationale:
Incorrect because placing the tablet in the patient's mouth next to the cheek would not allow for optimal absorption. The oral mucosa under the tongue is more permeable than the cheek, so placing the tablet under the tongue allows for faster and more efficient absorption.
Placing the tablet in the cheek could also increase the risk of the patient accidentally swallowing it.
Choice D rationale:
Correct because placing the tablet under the patient's tongue allows for rapid absorption and a quick onset of action. The sublingual route is the preferred method of administration for nitroglycerin because it allows the medication to bypass the digestive system and be absorbed directly into the bloodstream.
This method also allows for the patient to easily remove the tablet if they experience any side effects.
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