Answer to Question 1
C
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A Nitrogen buildup is not the primary cause of pressure ulcer formation.
B Prolonged illness or disease may place a patient at risk for pressure ulcer development, but it is not the primary cause of pressure ulcers.
C A pressure ulcer is a localized injury to the skin and other underlying tissue, usually over a body prominence, as a result of pressure or pressure in combination with shear and/or friction.
D Poor nutrition may place a patient at risk for pressure ulcer development, but it is not the primary cause of pressure ulcers.
Answer to Question 2
D
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A Although the agency chaplain may be a source for referral, such a referral is not the first action the nurse should take in assessing and supporting a patient's spirituality.
B The nurse needs first to assess a patient's spirituality to determine the patient's perceptions and belief system before attempting to assist the patient to use faith to get well.
C Providing a variety of religious literature may be ineffective, as it does not address the patient as an individual and does not assess the patient's personal spiritual needs. The nurse should first assess the patient's perception and belief system before implementing any intervention.
D To assess and support the patient's spirituality, the nurse should first determine the patient's perceptions and belief system. Exploring the patient's spirituality may reveal responses to health problems that require nursing intervention, or it may reveal the existence of a strong set of resources that enable the patient to cope effectively.
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