Chapter 48: Skin Integrity and Wound Care
Chapter 48: Skin Integrity and Wound Care
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE
... [Show More] CHOICE
1. The nurse is working on a medical-surgical unit that has been participating in a research project associated
with pressure ulcers. Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer
development?
a. Decreased level of consciousness
b. Adequate dietary intake
c. Shortness of breath
d. Muscular pain
ANS: A
Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect
themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or
to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear,
friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and an adequate
dietary intake are not included among the predisposing factors.
DIF:Understand (comprehension)REF:1186
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
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TOP: Assessment MSC: Reduction of Risk Potential
2. 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
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.
DIF:Understand (comprehension)REF:1185-1186 [Show Less]