Mr James London Flashcards
Mr London has very limited mobility, how often should you assist him to change position to prevent the development of a pressure injury?
A. Three hourly.
B. Two hourly.
C. Six hourly.
D. Four hourly.
B. Two hourly.
Pressure injuries form primarily as a result of:
A. Prolonged illness or disease.
B. Poor nutrition.
C. Tissue necrosis.
D. Nitrogen build up in the underlying tissue.
C. Tissue necrosis.
You conduct a Braden scale assessment for Mr London to assess his risk of developing a pressure injury. What risk factors are assessed using the Braden scale?
A. Physical condition, mental condition, activity, mobility, incontinence.
B. Nutrition, tissue perfusion, infection, age, shear force and friction, moisture.
C. Infection, haemorrhage, dehiscence, evisceration, fistulas.
D. Sensory perception, moisture, activity, mobility, nutrition, friction, shear.
D. Sensory perception, moisture, activity, mobility, nutrition, friction, shear.
Based on the Braden scale which of the following scores places him at the highest level of risk?
A. 18.
B. 12.
C. 16.
D. 23.
B. 12.
When Mr London is in a SUPINE position, what are the potential sites of pressure injury?
A. Neck hyperextension.
B. Unprotected pressure points at ileum, humerus, clavicle, knees and ankles.
C. Unprotected pressure points at sacrum, heels, scapulae, elbows and the back of the head.
D. The cheek he is lying on, and his abdomen.
C. Unprotected pressure points at sacrum, heels, scapulae, elbows and the back of the head.
You notice Mr London has partial-thickness skin loss involving the epidermis and possibly dermis in the sacral region, what stage of injury will you document in the patient records?
A. Stage II
B. Stage I.
C. Stage IV.
D. Stage III.
A. Stage II
During the assessment of Mr London, you note a reddened area over his coccyx. What should your next actions for him include?
A. Insert a urinary catheter to prevent moisture from urinary incontinence.
B. Massage the area and reposition the patient.
C. Reposition the patient off the coccyx and reassess in one hour.
D. Placing the patient in a Fowlers position and return in three hours.
C. Reposition the patient off the coccyx and reassess in one hour.
