Share This Link

"Pressure ulcers occur due to excessive friction on the skin." This statement is not accurate.
While friction can contribute to the development of pressure ulcers, it is not the primary pathophysiological factor.
Pressure ulcers primarily result from tissue ischemia and hypoxia, as well as pressure on the skin and underlying tissues.

"Damage to the skin and underlying tissues in pressure ulcers is primarily caused by a lack of proper hygiene." Hygiene is essential in preventing pressure ulcers, but it is not the primary cause of their development.
Pressure ulcers are mainly caused by sustained pressure on bony prominences, leading to reduced blood flow and oxygenation to the affected area.

"Pressure ulcers result from a hyperactive immune response in the affected area." This statement is not accurate.
Pressure ulcers are not primarily caused by a hyperactive immune response.
While inflammation may occur in response to tissue damage, it is not the root cause of pressure ulcers.

"Advanced age is the primary risk factor for pressure ulcers in individuals with diabetes." While advanced age is a risk factor for pressure ulcers, it is not the primary risk factor in individuals with diabetes.
Diabetes itself presents several risk factors, including compromised blood flow and oxygenation, which increase the susceptibility to pressure ulcers.

"Sensory deficits in diabetes make patients more resistant to pressure ulcers." This statement is incorrect.
Sensory deficits in diabetes, such as neuropathy, make patients more vulnerable to pressure ulcers.
These deficits can lead to reduced awareness of discomfort or pain, allowing pressure to be applied to areas without the patient's awareness.

"Poor nutrition and hydration do not contribute to the development of pressure ulcers in diabetic patients." This statement is not accurate.
Poor nutrition and hydration can significantly contribute to the development of pressure ulcers in diabetic patients.
Adequate nutrition and hydration are essential for maintaining skin integrity and supporting the healing process.

"The client's advanced age is the primary factor affecting wound healing." While advanced age can affect wound healing, it is not the primary factor in this case.
The client's history of vascular disease is a more significant contributing factor.

"The client's wound is not adequately protected from friction." Friction can impact wound healing, but in this case, vascular disease plays a more substantial role in impaired wound healing.

"The client's wound healing process is delayed due to a hyperactive immune response." A hyperactive immune response is not typically a primary factor in impaired wound healing associated with vascular disease.
The primary concern in vascular disease is compromised blood flow and tissue perfusion.

"Immobilization has no impact on the risk of pressure ulcer development." This statement is not accurate.
Immobilization significantly increases the risk of pressure ulcer development.
Prolonged pressure on the skin and tissues due to immobility can lead to tissue ischemia and pressure ulcer formation.

"The client's sensory deficits will prevent them from developing pressure ulcers." Sensory deficits, such as those resulting from a spinal cord injury, can actually increase the risk of pressure ulcers.
Patients with sensory deficits may not feel discomfort or pain, making them less likely to reposition themselves and relieve pressure on vulnerable areas.

"The client's spinal cord injury will lead to improved blood flow and oxygenation in the skin." This statement is not accurate.
A spinal cord injury does not lead to improved blood flow and oxygenation in the skin.
In fact, it can contribute to impaired mobility and sensory deficits, which increase the risk of pressure ulcers.

This choice is incorrect because the patient described in the question has intact skin, and there is no mention of an open wound with pus.
Pus is typically associated with wound infection, which is not a feature of stage 1 pressure ulcers.

The patient reporting a sharp pain in the affected area is not consistent with the characteristics of a stage 1 pressure ulcer.
Stage 1 pressure ulcers are typically not associated with pain because they only involve the superficial layers of the skin, and the underlying tissues are not affected.

Swelling around the wound is not a typical clinical manifestation of a stage 1 pressure ulcer.
In stage 1, the skin may appear red and feel warm to the touch due to inflammation, but there is no mention of swelling in the question.

Coldness to the touch is not a characteristic symptom of partial-thickness skin loss involving the epidermis and/or dermis.
This symptom is more indicative of compromised blood flow, such as in arterial insufficiency, and is not specific to pressure ulcers.

Redness around the wound is a characteristic symptom of partial-thickness skin loss (stage 2 pressure ulcer).
This redness is due to localized inflammation and represents damage to the epidermis and/or dermis, but it does not involve muscle or deeper tissues.

The statement, "My wound is deep, down to the muscle," suggests a full-thickness wound (stage 3 or 4 pressure ulcer) where muscle and deeper tissues are involved.
This statement does not align with the description provided in the question, which specifies partial-thickness skin loss.

Informing the client that surgery will not be needed for their severe pressure ulcer is not accurate and does not provide the necessary information for the client.
Surgical intervention may be required for severe pressure ulcers, especially when conservative treatments have been unsuccessful.

Informing the client that they'll need antibiotics after surgery is not universally applicable to all cases of pressure ulcer surgery.
Antibiotics may be prescribed if there is an infection, but this depends on the individual case and should be determined by the healthcare provider.

Stating that surgery will only address surface issues is not accurate.
Surgical interventions for severe pressure ulcers can involve debridement of necrotic tissue, closure of the wound, and sometimes reconstructive procedures.
The extent of surgery depends on the depth and severity of the ulcer.

Administering antibiotics to prevent infection is not the primary nursing intervention for a stage 3 pressure ulcer.
While infection prevention is important, optimizing nutrition and hydration (Choice D) takes precedence in this case.
Proper nutrition and hydration are essential for tissue healing and preventing further deterioration of the wound.
Infection prevention measures like antibiotics may be considered if there are signs of infection, but they are not the first-line intervention.

Assessing the patient's pain level and providing appropriate pain management (Choice B) is an important aspect of care for a patient with a stage 3 pressure ulcer, but it is not the highest priority.
Pain management should be addressed, but it should not take precedence over optimizing nutrition and hydration (Choice D), which is crucial for wound healing.

Educating the patient on the importance of mobility exercises (Choice C) is an essential aspect of preventing pressure ulcers, but for a patient with an existing stage 3 pressure ulcer, the priority should be on wound management and nutrition.
While mobility exercises are beneficial, they should not be prioritized over optimizing nutrition and hydration (Choice D) to support the healing process.

Encouraging frequent position changes and mobility exercises (Choice B) is a valuable intervention to prevent pressure ulcers, but in a client with an existing pressure ulcer and signs of infection, addressing the infection and underlying medical conditions take precedence.

Using specialized mattresses to offload pressure (Choice C) is an important part of pressure ulcer prevention and management, but it may not be the most immediate action needed for a client with signs of infection.
Addressing infection and underlying medical conditions (Choice A) should be the priority.

Providing education on proper wound care and prevention strategies (Choice D) is an essential nursing action but may not be the most immediate priority for a client with an active infection.
Managing the infection and addressing underlying medical conditions (Choice A) should come first.

Assessing the patient's pain level and providing appropriate pain management (Choice A) is important for a patient with cellulitis as a complication of a pressure ulcer.
However, the immediate priority should be to treat the underlying infection with antibiotics (Choice C).
Pain management can be addressed after initiating antibiotic therapy.

Encouraging frequent position changes and mobility exercises (Choice B) is a valuable intervention for preventing pressure ulcers but may not be the most immediate action needed for a patient with cellulitis.
Treating the infection with antibiotics (Choice C) takes precedence.

Optimizing the patient's nutrition and hydration (Choice D) is essential for overall health and wound healing, but in the context of cellulitis, treating the infection (Choice C) is the primary concern.
Once the infection is under control, nutritional support can be addressed.

Assessing the patient's pain level and providing appropriate pain management (Choice B) is important for the comfort of the patient but should not be the primary intervention for an unstageable pressure ulcer.
Wound management and offloading pressure (Choice A) take precedence.

Educating the patient on the importance of mobility exercises (Choice C) is a valuable aspect of pressure ulcer prevention but may not be immediately applicable to an unstageable ulcer.
The focus should be on wound management and pressure reduction (Choice A).

Collaborating with the healthcare team to address underlying medical conditions (Choice D) is essential for comprehensive patient care but may not be the most immediate action needed for an unstageable pressure ulcer.
Wound management and offloading pressure (Choice A) should be the initial priority.