This topic contains a solution. Click here to go to the answer
« previous next »

Author Question: The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The ... (Read 27 times)

mp14

  • Hero Member
  • *****
  • Posts: 534
on: Jul 22, 2018
The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious.
 
  Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer?
  a. Resistance
  b. Pressure
  c. Weight
  d. Stress

Question 2

Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
 
  a. The patient has fecal incontinence.
  b. The patient ate two thirds of breakfast.
  c. The patient has a raised red rash on the right shin.
  d. The patient's capillary refill is less than 2 seconds.


Related Topics

Need homework help now?

Ask unlimited questions for free

Ask a Question
Marked as best answer by a Subject Expert

babybsemail

  • Sr. Member
  • ****
  • Posts: 304
Reply #1 on: Jul 22, 2018
Answer to Question 1

ANS: B
Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capillary exceeds 15 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin breakdown. Resistance, stress, and weight are not the priority causes of pressure ulcers.

Answer to Question 2

ANS: A
The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the skin is moistened and softened, causing maceration. Eating a balanced diet is important for nutrition, but eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg again is a concern and can affect the integrity of the skin, but it is located on the shin, which is not a high-risk area for skin breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary response is within normal limits.


mp14

  • Member
  • Posts: 534
Reply 2 on: Jul 22, 2018
Great answer, keep it coming :)

Missbam101

  • Member
  • Posts: 341
Reply 3 on: Yesterday
:D TYSM

« previous next »
 

Did you know?

The tallest man ever known was Robert Wadlow, an American, who reached the height of 8 feet 11 inches. He died at age 26 years from an infection caused by the immense weight of his body (491 pounds) and the stress on his leg bones and muscles.

Did you know?

Each year in the United States, there are approximately six million pregnancies. This means that at any one time, about 4% of women in the United States are pregnant.

Did you know?

Adults are resistant to the bacterium that causes Botulism. These bacteria thrive in honey – therefore, honey should never be given to infants since their immune systems are not yet resistant.

Did you know?

The first monoclonal antibodies were made exclusively from mouse cells. Some are now fully human, which means they are likely to be safer and may be more effective than older monoclonal antibodies.

Did you know?

The U.S. Preventive Services Task Force recommends that all women age 65 years of age or older should be screened with bone densitometry.

Patient Position for Posterior Percussion Patient Position for Posterior Percussion
B, The nurse teaches the postoperative client to use an incentive spirometer to expand the lungs. B, The nurse teaches the postoperative client to use an incentive spirometer to expand the lungs.
The nurse applies a pulse oximeter sensor on the client’s finger. The nurse applies a pulse oximeter sensor on the client’s finger.
Urinary catheterization. The procedure involves the insertion of a flexible tube, or catheter, throu Urinary catheterization. The procedure involves the insertion of a flexible tube, or catheter, throu
Patient teaching: ear assessment Patient teaching: ear assessment
Preparing a Manual Patient Ledger. Preparing a Manual Patient Ledger.
Video: Introduction to Herpes

For a complete list of videos, visit our video library