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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?

A.

Document on the reddened area

B.

Ask the client how the area became reddened

C.

Assess the client’s diet

D.

Relieve pressure from the right heel

Answer and Explanation

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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Related Questions

Correct Answer is ["B","C","E"]

Explanation

Echinacea is commonly used to boost the immune system and prevent colds and other infections.Ginseng is a stimulant that is often used to improve physical performance and reduce fatigue. Aloe is a natural anti-inflammatory and antibacterial agent that is often used to promote healing of burns, cuts, and other skin injuries.

Ginkgo biloba does not cause fibrin clot formation, but rather has been shown to have an anticoagulant effect, meaning it can decrease the clotting ability of the blood. Chamomile is not known for enhancing the immune response to influenza A, but rather for its calming effects and its use as a sleep aid.

Correct Answer is B

Explanation

False reassurance is a statement that may be intended to comfort or calm the parents, but does not provide any real information or address their concerns. An example of false reassurance in this scenario would be "Don't worry. I'm sure he will be fine."

While the statement "Your child will receive prompt care" and "We care for many 5-year-olds here" are appropriate and true statements, "I have been a pediatric nurse for ten years" is not relevant to the immediate situation and does not provide any information to the parents about their child's condition or care.

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