Pathophysiology of the integumentary system > Pathophysiology
Exam Review
Wounds and Pressure Ulcers
Total Questions : 15
Showing 15 questions, Sign in for moreA nurse is caring for a client who has been bedridden for an extended period. The client has developed a pressure ulcer on their sacrum.
Which of the following statements best describes the pathophysiology of pressure ulcers?
Explanation
Choice A rationale:
"Pressure ulcers occur due to excessive friction on the skin." This statement is not accurate.
While friction can contribute to the development of pressure ulcers, it is not the primary pathophysiological factor.
Pressure ulcers primarily result from tissue ischemia and hypoxia, as well as pressure on the skin and underlying tissues.
Choice B rationale:
"Damage to the skin and underlying tissues in pressure ulcers is primarily caused by a lack of proper hygiene." Hygiene is essential in preventing pressure ulcers, but it is not the primary cause of their development.
Pressure ulcers are mainly caused by sustained pressure on bony prominences, leading to reduced blood flow and oxygenation to the affected area.
Choice C rationale:
"Ischemia and tissue hypoxia play a significant role in the development of pressure ulcers." This statement is correct.
Ischemia (reduced blood flow) and tissue hypoxia (inadequate oxygen supply) are key pathophysiological factors in the development of pressure ulcers.
Prolonged pressure on the skin and tissues leads to compromised blood flow, tissue damage, and ultimately, pressure ulcer formation.
Choice D rationale:
"Pressure ulcers result from a hyperactive immune response in the affected area." This statement is not accurate.
Pressure ulcers are not primarily caused by a hyperactive immune response.
While inflammation may occur in response to tissue damage, it is not the root cause of pressure ulcers.
A client with diabetes is receiving care from a nurse. The client is at risk of developing pressure ulcers due to their medical condition.
What statement accurately identifies a risk factor for pressure ulcers in this client?
Explanation
Choice A rationale:
"Advanced age is the primary risk factor for pressure ulcers in individuals with diabetes." While advanced age is a risk factor for pressure ulcers, it is not the primary risk factor in individuals with diabetes.
Diabetes itself presents several risk factors, including compromised blood flow and oxygenation, which increase the susceptibility to pressure ulcers.
Choice B rationale:
"Sensory deficits in diabetes make patients more resistant to pressure ulcers." This statement is incorrect.
Sensory deficits in diabetes, such as neuropathy, make patients more vulnerable to pressure ulcers.
These deficits can lead to reduced awareness of discomfort or pain, allowing pressure to be applied to areas without the patient's awareness.
Choice C rationale:
"Poor nutrition and hydration do not contribute to the development of pressure ulcers in diabetic patients." This statement is not accurate.
Poor nutrition and hydration can significantly contribute to the development of pressure ulcers in diabetic patients.
Adequate nutrition and hydration are essential for maintaining skin integrity and supporting the healing process.
Choice D rationale:
"Individuals with diabetes are more prone to pressure ulcers due to compromised blood flow and oxygenation." This statement is correct.
Diabetes can lead to compromised blood flow (peripheral vascular disease) and oxygenation (due to vascular damage), making individuals with diabetes more prone to pressure ulcers.
A nurse is providing education to a group of caregivers about preventing pressure ulcers in bedridden patients.
Which interventions should the caregivers implement? (Select three).
Explanation
Choice A rationale:
"Frequent repositioning of the patient." Frequent repositioning is crucial in preventing pressure ulcers.
It helps redistribute pressure on vulnerable areas, reducing the risk of tissue ischemia and damage.
Choice B rationale:
"Maintaining a dry and clean skin surface." Keeping the skin clean and dry is essential in preventing pressure ulcers.
Moisture can contribute to skin breakdown, so maintaining dryness helps preserve skin integrity.
Choice C rationale:
"Applying pressure-relieving cushions or devices." Using pressure-relieving cushions or devices can help distribute pressure more evenly and reduce the risk of pressure ulcers in bedridden patients.
Choice D rationale:
"Increasing the intake of sugar-rich foods." This choice is not appropriate for preventing pressure ulcers.
Increasing sugar-rich foods can lead to complications such as diabetes and should not be a part of pressure ulcer prevention strategies.
Choice E rationale:
"Encouraging immobility in bedridden patients." Encouraging immobility is not a recommended strategy for preventing pressure ulcers.
Immobility increases the risk of pressure ulcers, and caregivers should aim to promote mobility and reposition patients regularly.
A nurse is assessing a client who has developed a wound on their lower leg. The client has a history of vascular disease.
Which of the following factors is most likely contributing to the client's impaired wound healing process?
Explanation
Choice A rationale:
"The client's advanced age is the primary factor affecting wound healing." While advanced age can affect wound healing, it is not the primary factor in this case.
The client's history of vascular disease is a more significant contributing factor.
Choice B rationale:
"The client's wound is not adequately protected from friction." Friction can impact wound healing, but in this case, vascular disease plays a more substantial role in impaired wound healing.
Choice C rationale:
"Vascular disease may lead to compromised blood flow and oxygenation in the affected area." This statement is correct.
Vascular disease can impair blood flow and oxygenation to tissues, significantly affecting wound healing.
Reduced blood flow deprives tissues of necessary nutrients and oxygen, leading to delayed healing.
Choice D rationale:
"The client's wound healing process is delayed due to a hyperactive immune response." A hyperactive immune response is not typically a primary factor in impaired wound healing associated with vascular disease.
The primary concern in vascular disease is compromised blood flow and tissue perfusion.
A client has been immobile for an extended period due to a spinal cord injury. The nurse is assessing the client for the risk of developing pressure ulcers.
Which statement regarding the client's immobility and pressure ulcer risk is accurate?
Explanation
Choice A rationale:
"Immobilization has no impact on the risk of pressure ulcer development." This statement is not accurate.
Immobilization significantly increases the risk of pressure ulcer development.
Prolonged pressure on the skin and tissues due to immobility can lead to tissue ischemia and pressure ulcer formation.
Choice B rationale:
"The client's sensory deficits will prevent them from developing pressure ulcers." Sensory deficits, such as those resulting from a spinal cord injury, can actually increase the risk of pressure ulcers.
Patients with sensory deficits may not feel discomfort or pain, making them less likely to reposition themselves and relieve pressure on vulnerable areas.
Choice C rationale:
"Prolonged immobility increases the risk of pressure ulcers due to decreased tissue perfusion." This statement is accurate.
Prolonged immobility reduces tissue perfusion (blood flow) to areas under pressure, increasing the risk of pressure ulcer development.
Choice D rationale:
"The client's spinal cord injury will lead to improved blood flow and oxygenation in the skin." This statement is not accurate.
A spinal cord injury does not lead to improved blood flow and oxygenation in the skin.
In fact, it can contribute to impaired mobility and sensory deficits, which increase the risk of pressure ulcers.
A nurse is caring for a patient with a pressure ulcer that presents as non-blanchable erythema with intact skin.
What clinical manifestation is the nurse likely to observe in this patient?
Explanation
Choice A rationale:
The nurse is likely to observe warmth around the pressure ulcer site with intact skin.
This is a characteristic clinical manifestation of a stage 1 pressure ulcer.
In stage 1 pressure ulcers, there is non-blanchable erythema (redness) of the skin due to localized inflammation, and the area may feel warm to the touch.
However, the skin is still intact, and there are no open wounds or pus.
Choice B rationale:
This choice is incorrect because the patient described in the question has intact skin, and there is no mention of an open wound with pus.
Pus is typically associated with wound infection, which is not a feature of stage 1 pressure ulcers.
Choice C rationale:
The patient reporting a sharp pain in the affected area is not consistent with the characteristics of a stage 1 pressure ulcer.
Stage 1 pressure ulcers are typically not associated with pain because they only involve the superficial layers of the skin, and the underlying tissues are not affected.
Choice D rationale:
Swelling around the wound is not a typical clinical manifestation of a stage 1 pressure ulcer.
In stage 1, the skin may appear red and feel warm to the touch due to inflammation, but there is no mention of swelling in the question.
A client with a pressure ulcer reports partial-thickness skin loss involving the epidermis and/or dermis.
Which symptom should the nurse expect to find during the assessment?
Explanation
Choice A rationale:
Coldness to the touch is not a characteristic symptom of partial-thickness skin loss involving the epidermis and/or dermis.
This symptom is more indicative of compromised blood flow, such as in arterial insufficiency, and is not specific to pressure ulcers.
Choice B rationale:
Redness around the wound is a characteristic symptom of partial-thickness skin loss (stage 2 pressure ulcer).
This redness is due to localized inflammation and represents damage to the epidermis and/or dermis, but it does not involve muscle or deeper tissues.
Choice C rationale:
Tenderness when touching the wound is an expected symptom in partial-thickness skin loss involving the epidermis and/or dermis (stage 2 pressure ulcer).
The presence of tenderness is indicative of ongoing tissue damage and inflammation in the affected area.
Choice D rationale:
The statement, "My wound is deep, down to the muscle," suggests a full-thickness wound (stage 3 or 4 pressure ulcer) where muscle and deeper tissues are involved.
This statement does not align with the description provided in the question, which specifies partial-thickness skin loss.
A nurse is assessing a patient with a pressure ulcer. Select all the appropriate actions the nurse should take during the assessment.
Explanation
Choice A rationale:
Measuring the wound size and depth is an essential action during the assessment of a pressure ulcer.
It helps in determining the severity of the ulcer, tracking its progress, and planning appropriate wound care interventions.
Choice B rationale:
Administering pain management as needed is not specifically related to the assessment phase but is an important aspect of pressure ulcer management overall.
Pain management is crucial to ensure the patient's comfort and adherence to the treatment plan, but it is not a direct assessment action.
Choice C rationale:
Checking vital signs for signs of infection is an appropriate action during the assessment of a patient with a pressure ulcer.
Fever and other vital sign abnormalities may indicate the presence of an infection in the wound, which requires immediate attention.
Choice D rationale:
Assessing the patient's nutritional status is a critical part of the assessment process for a patient with a pressure ulcer.
Malnutrition can delay wound healing, so assessing nutritional needs and addressing deficiencies is essential.
Choice E rationale:
Ensuring proper mobility to prevent pressure on vulnerable areas is an appropriate action during the assessment.
Assessing the patient's mobility status helps in identifying areas at risk for pressure ulcers and developing preventive strategies.
However, this action may also extend beyond the assessment phase and involve ongoing care.
A client with a severe pressure ulcer is being considered for surgical intervention. What should the nurse educate the client about regarding this potential treatment?
Explanation
Choice A rationale:
Informing the client that surgery will not be needed for their severe pressure ulcer is not accurate and does not provide the necessary information for the client.
Surgical intervention may be required for severe pressure ulcers, especially when conservative treatments have been unsuccessful.
Choice B rationale:
Educating the client that surgery may involve removing damaged tissue is an important aspect of preparing them for potential surgical intervention.
Surgical debridement may be necessary to remove necrotic or infected tissue and promote wound healing.
Choice C rationale:
Informing the client that they'll need antibiotics after surgery is not universally applicable to all cases of pressure ulcer surgery.
Antibiotics may be prescribed if there is an infection, but this depends on the individual case and should be determined by the healthcare provider.
Choice D rationale:
Stating that surgery will only address surface issues is not accurate.
Surgical interventions for severe pressure ulcers can involve debridement of necrotic tissue, closure of the wound, and sometimes reconstructive procedures.
The extent of surgery depends on the depth and severity of the ulcer.
A nurse is selecting a dressing for a patient's pressure ulcer based on wound characteristics. What factors should the nurse consider when making this decision?
Explanation
Choice A rationale:
The wound's warmth to the touch is not a primary factor to consider when selecting a dressing for a pressure ulcer.
The choice of dressing should primarily be based on the wound's characteristics, such as its depth, exudate level, and tissue involvement.
Choice B rationale:
The presence of a foul odor from the wound is an important factor to consider when selecting a dressing.
Malodorous wounds may indicate infection or necrotic tissue, and appropriate wound dressings can help manage odor and promote healing.
Choice C rationale:
The extent of tissue damage, including muscle and bone involvement, is a critical factor in choosing an appropriate dressing for a pressure ulcer.
Dressings should be selected based on the depth of the wound and the extent of tissue damage to support healing and prevent complications.
Choice D rationale:
The patient's mobility and pressure on vulnerable areas are essential considerations when selecting a dressing.
Dressings should help offload pressure from vulnerable areas and promote mobility while providing optimal wound care.
The choice of dressing should support the overall management of the patient's condition.
A nurse is caring for a patient with a stage 3 pressure ulcer. What nursing intervention should the nurse prioritize based on the information provided in the text?
Explanation
Choice A rationale:
Administering antibiotics to prevent infection is not the primary nursing intervention for a stage 3 pressure ulcer.
While infection prevention is important, optimizing nutrition and hydration (Choice D) takes precedence in this case.
Proper nutrition and hydration are essential for tissue healing and preventing further deterioration of the wound.
Infection prevention measures like antibiotics may be considered if there are signs of infection, but they are not the first-line intervention.
Choice B rationale:
Assessing the patient's pain level and providing appropriate pain management (Choice B) is an important aspect of care for a patient with a stage 3 pressure ulcer, but it is not the highest priority.
Pain management should be addressed, but it should not take precedence over optimizing nutrition and hydration (Choice D), which is crucial for wound healing.
Choice C rationale:
Educating the patient on the importance of mobility exercises (Choice C) is an essential aspect of preventing pressure ulcers, but for a patient with an existing stage 3 pressure ulcer, the priority should be on wound management and nutrition.
While mobility exercises are beneficial, they should not be prioritized over optimizing nutrition and hydration (Choice D) to support the healing process.
Choice D rationale:
Optimizing the patient's nutrition and hydration (Choice D) is the most appropriate nursing intervention for a patient with a stage 3 pressure ulcer.
Proper nutrition and hydration are essential for tissue repair and wound healing.
Inadequate nutrition can delay healing and increase the risk of complications, making this the highest priority intervention.
A client presents with a pressure ulcer and signs of infection. Which nursing action aligns with the information in the text?
Explanation
Choice A rationale:
Consulting with the healthcare team to address underlying medical conditions (Choice A) is the most appropriate nursing action for a client with a pressure ulcer and signs of infection.
Pressure ulcers can develop or worsen due to underlying medical conditions such as diabetes, vascular disease, or immunosuppression.
Addressing these underlying conditions is essential for effective wound management and preventing further complications.
Choice B rationale:
Encouraging frequent position changes and mobility exercises (Choice B) is a valuable intervention to prevent pressure ulcers, but in a client with an existing pressure ulcer and signs of infection, addressing the infection and underlying medical conditions take precedence.
Choice C rationale:
Using specialized mattresses to offload pressure (Choice C) is an important part of pressure ulcer prevention and management, but it may not be the most immediate action needed for a client with signs of infection.
Addressing infection and underlying medical conditions (Choice A) should be the priority.
Choice D rationale:
Providing education on proper wound care and prevention strategies (Choice D) is an essential nursing action but may not be the most immediate priority for a client with an active infection.
Managing the infection and addressing underlying medical conditions (Choice A) should come first.
A nurse is assessing a patient at risk for pressure ulcers. Which interventions are appropriate for preventing pressure ulcers based on the information in the text? (Select all that apply)
Explanation
Choice A rationale:
Optimizing nutrition and hydration (Choice A) is a crucial intervention for preventing pressure ulcers.
Proper nutrition supports tissue health and wound healing.
Dehydration and malnutrition can increase the risk of developing pressure ulcers or exacerbate existing ones.
Choice B rationale:
Administering antibiotics prophylactically (Choice B) is not a routine intervention for preventing pressure ulcers.
Antibiotics should be used to treat infections when they occur but should not be given prophylactically unless there are specific clinical indications.
Choice C rationale:
Promoting mobility and activity (Choice C) is an effective strategy for preventing pressure ulcers.
Regular position changes and mobility exercises help relieve pressure on vulnerable areas of the skin, reducing the risk of pressure ulcers.
Choice D rationale:
Using appropriate support surfaces and equipment (Choice D) is essential for preventing pressure ulcers in patients at risk.
Support surfaces, such as pressure-reducing mattresses, can help distribute pressure evenly and reduce the risk of tissue damage.
Choice E rationale:
Educating patients, caregivers, and healthcare professionals on prevention strategies (Choice E) is a vital component of pressure ulcer prevention.
Proper education helps raise awareness and ensures that everyone involved in patient care understands the importance of preventive measures.
A client has developed cellulitis as a complication of a pressure ulcer. What action should the nurse prioritize according to the information provided in the text?
Explanation
Choice A rationale:
Assessing the patient's pain level and providing appropriate pain management (Choice A) is important for a patient with cellulitis as a complication of a pressure ulcer.
However, the immediate priority should be to treat the underlying infection with antibiotics (Choice C).
Pain management can be addressed after initiating antibiotic therapy.
Choice B rationale:
Encouraging frequent position changes and mobility exercises (Choice B) is a valuable intervention for preventing pressure ulcers but may not be the most immediate action needed for a patient with cellulitis.
Treating the infection with antibiotics (Choice C) takes precedence.
Choice C rationale:
Administering antibiotics to treat the infection (Choice C) is the most appropriate nursing action for a client with cellulitis as a complication of a pressure ulcer.
Cellulitis is a bacterial infection that requires prompt antibiotic treatment to prevent its spread and complications.
Choice D rationale:
Optimizing the patient's nutrition and hydration (Choice D) is essential for overall health and wound healing, but in the context of cellulitis, treating the infection (Choice C) is the primary concern.
Once the infection is under control, nutritional support can be addressed.
A nurse is caring for a patient with an unstageable pressure ulcer. What is an appropriate nursing intervention based on the information in the text?
Explanation
Choice A rationale:
Using specialized mattresses to offload pressure (Choice A) is an appropriate nursing intervention for a patient with an unstageable pressure ulcer.
Unstageable ulcers have necrotic tissue or eschar covering the wound, making it impossible to assess the depth and stage of the ulcer.
Specialized mattresses can help relieve pressure on the ulcer and promote healing.
Choice B rationale:
Assessing the patient's pain level and providing appropriate pain management (Choice B) is important for the comfort of the patient but should not be the primary intervention for an unstageable pressure ulcer.
Wound management and offloading pressure (Choice A) take precedence.
Choice C rationale:
Educating the patient on the importance of mobility exercises (Choice C) is a valuable aspect of pressure ulcer prevention but may not be immediately applicable to an unstageable ulcer.
The focus should be on wound management and pressure reduction (Choice A).
Choice D rationale:
Collaborating with the healthcare team to address underlying medical conditions (Choice D) is essential for comprehensive patient care but may not be the most immediate action needed for an unstageable pressure ulcer.
Wound management and offloading pressure (Choice A) should be the initial priority.
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