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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When assessing bowel elimination, the factors to be considered are: Age, use of laxatives or other bowel medications, dietary habits and fluid intake, history of bowel diseases or surgeries. Gender does not have an influence on bowel movements.
Geriatrics often have slowed bowel movements compared to the young.
Diet high in fiber usually enhances bowel movement.
Increased fluid intake improves stool consistency.
Correct Answer is D
Explanation
According to Maslow's hierarchy of needs, all people have basic human needs that must be fulfilled in order to achieve self-actualization and reach their full potential.
These basic human needs include physiological needs such as air, water, food, and shelter; safety needs such as physical safety, emotional security, and financial stability; love and belonging needs such as the need for love, affection, friendship, and community; esteem needs such as the need for self-esteem, confidence, achievement, and respect from others; and self-actualization needs such as the need for personal growth, creativity, and fulfillment of one's potential.
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