The nurse knows that which of the following factors contribute to the development of pressure ulcers? (Select all that apply.)
a. Friction and shear
b. Immobility
c. Poor nutrition
d. Moisture and ammonia
e. Uncontrolled pain
A, B, C, D
Factors such as incontinence, friction and shear, immobility, loss of sensory perception, reduced level of activity, and poor nutrition contribute to pressure ulcer formation. Moisture and ammonia from incontinence soften the skin, allowing the skin to become susceptible to breakdown. Uncontrolled pain does not contribute to the development of pressure ulcers.
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A client is admitted to the unit with swelling of both lower extremities. During the physical exam, the nurse palpates the client's skin with the pads of her fingers and finds that the indention formed is deep, but lasts only a short time
This finding indicates: 1. Pitting edema. 2. Loss of skin elasticity. 3. Decrease sensation. 4. Increased skin turgor.
The postpartum nurse is caring for a client with an epidural catheter in place for opioid analgesic administration following cesarean birth
If the client develops respiratory depression and requires naloxone (Narcan) as an antidote, the client may complain of which of the following? 1. Increase in her pain level 2. Decrease in her pain level 3. Increase in the amount of itching from the opioid used in the epidural 4. Decrease in the amount of itching from the opioid used in the epidural
When explaining the basis of pain, which of the following would the nurse include? Select all that apply
A) Physiologic B) Psychological C) Cutaneous D) Somatic E) Visceral