Immobility is a major risk factor for pressure ulcers. In caring ...

[jazziefee]

Immobility is a major risk factor for pressure ulcers. In caring for the patient who is immobilized, the nurse needs to be aware that
 
  a. Breaks in skin integrity are easy to heal.
  b. Preventing a pressure ulcer is more expensive than treating one.
  c. Immobilized patients can develop skin breakdown within 3 hours.
  d. Pressure ulcers are caused by a sudden influx of oxygen to the tissue.

Question 2

The nurse is caring for a patient who has been diagnosed with a stroke. As part of her ongoing care, the nurse should
 
  a. Encourage the patient to perform as many self-care activities as possible.
  b. Provide a complete bed bath to promote patient comfort.
  c. Place the patient on bed rest to prevent fatigue.
  d. Understand that the patient will not eat owing to a decreased energy need.

[ebenov]

Answer to Question 1

ANS: C
Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore, preventive nursing interventions are imperative. An older adult who is immobilized can develop skin breakdown within 3 hours. Tissue metabolism depends on the supply of oxygen and nutrients to and the elimination of metabolic wastes from the blood. Pressure affects cellular metabolism by decreasing or totally eliminating tissue circulation.

Answer to Question 2

ANS: A
Nurses should encourage the patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility. Sometimes nurses inadvertently contribute to a patient's immobility by providing unnecessary help with activities such as bathing and transferring. Placing the patient on bed rest without sufficient ambulation leads to loss of mobility and functional decline, resulting in weakness, fatigue, and increased risk for falls. Anorexia and insufficient assistance with eating lead to malnutrition.