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 on 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
Relieving pressure from the heel is essential to prevent further damage to the skin and underlying tissues. This can be achieved by using specialized cushions, repositioning the client regularly, or elevating the foot to reduce pressure.
While documenting the reddened area is important to monitor the progression of the wound, asking the client how the area became reddened and assessing their diet may not be the most relevant interventions in this situation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
The appropriate interventions for clients with visual impairments are to identify yourself, ensure adequate lighting, and provide discharge instructions in a larger font.
Speaking louder is not always helpful as it can distort the sound, making it harder to understand. It's also not appropriate to talk to other people in the room, as the client may not know who is being addressed.
Correct Answer is B
Explanation
This statement acknowledges the client's feelings and shows that the nurse is interested in hearing more about their experience. It allows the client to share their emotions and concerns, which can help them to process their diagnosis and feel supported.
The other statements do not demonstrate empathy as effectively. "Tomorrow will be better" minimizes the client's current feelings and does not acknowledge the seriousness of the diagnosis. "I believe you can overcome this" focuses on the nurse's beliefs rather than the client's feelings. "What is your biggest fear about this diagnosis?" may be too direct and could put the client on the spot, potentially causing discomfort or anxiety.
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