You are the nurse caring for a patient who has paraplegia following a hunting accident. You know to assess regularly for the development of pressure ulcers on this patient. What rationale would you cite for this nursing action?
A) You know that this patient will have a decreased level of consciousness.
B) You know that this patient may not be motivated to prevent pressure ulcers.
C) You know that the risk for pressure ulcers is directly related to the duration of immobility.
D) You know that the risk for pressure ulcers is related to what caused the immobility.
Ans: C
Feedback:
The development of pressure ulcers is directly related to the duration of immobility: If pressure continues long enough, small vessel thrombosis and tissue necrosis occur, and a pressure ulcer results. The cause of the immobility is not what is important in the development of a pressure ulcer; the duration of the immobility is what matters. Paraplegia does not result in a decreased level of consciousness and there is no reason to believe that the patient does not want to prevent pressure ulcers.
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