The nurse is caring for a patient who was involved in an ...

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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.

[babybsemail]

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.

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Gracias!

[rleezy04]

Excellent