which among the following is not the cause of pressure ulcers

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. Which among the following is NOT the cause of pressure ulcers?

A. Immobility
B. Poor nutrition
C. Moisture
D. Adequate perfusion

Correct answer: D

Rationale:

2. What is not appropriate client education on the preventing the spread of methicillin- resistance Staphylococcus aureus (MRSA)?

A. Avoid contact sports until the infection has cleared
B. Use a bath sponge to cleanse the skin
C. Wash hands with soap and water before and after touching the infected area
D. Use an antibacterial soap when showering

Correct answer: B

Rationale:

3. Where will the nurse collect the most reliable source of pain assessment?

A. From the nurse-to-nurse bedside report
B. From a medical surgical book
C. From the client
D. From the client's chart

Correct answer: C

Rationale:

4. What is the priority nursing diagnosis for a client with immobility?

A. Constipation related to immobility
B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.