A client has a reddened area on his right heel.
What is the best intervention by the nurse to prevent further skin and tissue breakdown?
Document the reddened area
Ask the client how the area became reddened
Assess the client's diet
Relieve pressure from the right heel
The Correct Answer is D
The best intervention by the nurse to prevent further skin and tissue breakdown on a reddened area on a client’s right heel is to relieve pressure from the right heel1.
Heels are particularly vulnerable to skin breakdown and when patients lie supine, all of the pressure of their lower legs and feet rest on the heels1.
Preventing heel ulcers primarily involves the use of simple devices, like pillows and offloading devices, to protect delicate heels1.
Choice A is not correct because documenting the reddened area alone will not prevent further skin and tissue breakdown.
Choice B is not correct because asking the client how the area became reddened alone will not prevent further skin and tissue breakdown.
Choice C is not correct because assessing the client’s diet alone will not prevent further skin and tissue breakdown.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Scheduling massages as well as taking prescribed medication for pain control is an example of complementary therapy.
Complementary therapy refers to the use of non-mainstream practices in conjunction with conventional medical treatment.
In this case, the client is using massage therapy, a complementary approach, along with their prescribed medication to manage their pain.
Choice A is not an appropriate response because pain therapy is a broad term that can refer to any approach used to manage pain.
Choice B is not an appropriate response because nociceptive pain control refers to the management of pain caused by tissue damage or inflammation.
Choice C is not an appropriate response because non-therapeutic communication refers to communication that does not promote healing or well-being.
Correct Answer is B
Explanation
The client is experiencing neuropathic pain.
Pain after amputation can involve both nociceptive pain due to bone and soft tissue injury and neuropathic pain from direct neural trauma and central sensitization1.
This can lead to a complicated, mixed form of pain.
Choice A is not the correct answer because nociceptive pain is not the only type of pain that can occur after amputation.
Choice C is not the correct answer because cutaneous pain is not the type of pain being described.
Choice D is not the correct answer because visceral pain is not the type of pain being described.
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