hard · NCLEX-RN basic-care
The nurse interprets the clinical findings on Clara Vance's right heel. Which pathophysiological mechanism best accounts for the new localized skin discoloration, bogginess, and coolness? Apply the response specifically to this case: immobile client with a purple nonblanchable heel, evolving deep-tissue pressure injury, off-loading failure, moisture, nutrition deficits, and perfusion limits.
- Microvascular occlusion and tissue ischemia from sustained pressure over a bony prominence
- Superficial epidermal shearing and moisture-associated skin damage from urinary wetness
- Acute macrovascular arterial occlusion from a thromboembolism in the right lower extremity
- Chronic venous congestion and fluid pooling due to lower extremity dependency
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