Practice Question
Which area(s) of the body will the nurse observe for pressure injuries in a bed bound client? Select all that apply. One, some, or all responses may be correct.
Answer Choices:
Correct Answer:
Elbows
Rationale:
Elbows
🟠The elbows are bony prominences with little natural cushioning, making them highly prone to pressure injuries in immobile clients.
🟠Continuous contact with the bed surface decreases capillary blood flow, causing ischemia and tissue necrosis if unrelieved.
🟠 Friction occurs when a client’s elbows are rubbed against bed linens during movement, further damaging epidermal layers.
🟠 Protective devices such as foam pads or elbow protectors can help reduce direct pressure.
🟠 Regular assessment and repositioning are crucial to prevent skin breakdown at this site.
Heels
🟠 The heels are among the most common sites of pressure injury because they rest directly on the bed in a supine position.
🟠 The Achilles tendon and calcaneus bone lie close to the skin, making tissue more vulnerable to ischemia.
🟠 Off-loading devices, such as heel protectors or pillows under the calves, relieve direct pressure.
🟠 Skin inspection of the heels should be frequent, as injuries here may go unnoticed until advanced.
🟠 Heel ulcers can progress rapidly due to poor perfusion in distal extremities, especially in older adults or diabetic clients.
Back of the head
🟠 The occiput (back of the head) is another bony prominence at risk in clients who lie supine for extended periods.
🟠 Thin tissue covering the skull means sustained pressure quickly compromises circulation, leading to breakdown.
🟠 Infants and frail older adults are especially vulnerable due to limited subcutaneous padding.
🟠 Use of gel pads or specialized pillows helps distribute weight evenly and reduces pressure.
🟠 Frequent repositioning of the head and maintaining proper alignment are important to preserve skin integrity.
Coccyx
🟠 The coccyx and sacrum are primary pressure sites in bedbound clients due to their central contact with the bed surface.
🟠 Prolonged pressure here restricts blood supply and is worsened by shear and friction from sliding down in bed.
🟠 Incontinence increases risk, as moisture and bacteria accelerate skin breakdown in this region.
🟠 Preventive strategies include regular repositioning, barrier creams, and moisture control measures.
🟠 The coccyx is a common site for stage III and IV pressure ulcers, so vigilance in assessment is critical.
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This question is from Gerontology Exam 1 which contains 46 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Health Assessment
- Answer Choices: 5