You are the nurse caring for a patient who is immobile due to a hunting accident. You know to assess for the development of pressure ulcers on this patient. Why would you know to do this?
A) You know that this patient will be immobile only until the cast comes off.
B) You know that this patient has a lot of support in maintaining proper alignment.
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. Option A is incorrect because a cast can remain in place for months. Option B is incorrect because a patient with support for maintaining proper alignment has less chance of developing a pressure ulcer than a patient without this support. Option D is incorrect because 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.
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