A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.
Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

The correct answer is Choice D.

Choice D rationale: Keeping the nails trimmed short is crucial for a child with eczema because it minimizes the damage done when the child scratches their skin. Short nails reduce the risk of breaking the skin and causing infections or further irritation, which can exacerbate eczema symptoms. This preventive measure helps maintain the skin's integrity and reduces the risk of secondary infections.

Choice A rationale: Allowing the child to wear only 100% cotton clothing can help reduce skin irritation as cotton is a soft, breathable fabric. However, it is not as directly related to preventing the harm caused by scratching.

Choice B rationale: Applying baby lotion to the skin can help keep the skin moisturized, but it might not be sufficient for eczema management. A more intensive emollient or specific eczema treatment may be needed.

Choice C rationale: Bathing the child daily with bath oil can help moisturize the skin, but over-bathing can sometimes exacerbate eczema. It's important to use gentle, non-irritating bath products and to follow other guidelines, such as trimming nails.

Choice A rationale

Clarifying reality with the client about delusional thoughts is not the most effective approach when dealing with a client with dementia who is experiencing agitation and delusional thoughts. The cognitive impairment associated with dementia may make it difficult for the client to understand or accept the clarification, which could lead to increased frustration and agitation.

Choice B rationale

Reducing the client’s interaction with others during the day is not the most appropriate approach in this situation. It may lead to increased social isolation and could potentially worsen the client’s agitation and delusions. It does not directly address the client’s emotional distress.

Choice C rationale

Awakening the client earlier for daily morning care may further disrupt the client’s sleep patterns and potentially worsen agitation. It does not address the underlying issue of delusional thoughts and the client’s emotional distress.

Choice D rationale

Using distraction and therapeutic communication skills is the most suitable approach for a client with dementia who is experiencing agitation and delusional thoughts. Distraction techniques can help redirect the client’s focus away from distressing thoughts, and therapeutic communication skills, such as active listening and validation, can help the client feel understood and supported.