A client is bedridden and appears to be frail and malnourished. Which nursing interventions will most effectively prevent skin injury? (Select all that apply.)
Cleansing the skin routinely after soiling occurs.
Applying moisturizer to dry areas of skin.
Using a Hoyer lift for all transfers.
Massaging the client’s reddened shoulders and heels.
Repositioning the client once per shift.
Correct Answer : A,B,C
Choice A reason: Cleansing the skin routinely after soiling occurs is an effective intervention to prevent skin injury. This is because soiling from urine, feces, sweat, or wound drainage can irritate the skin and cause inflammation, infection, or breakdown. The nurse should use a gentle cleanser and warm water and pat the skin dry. The nurse should also avoid using harsh chemicals, alcohol, or perfumes on the skin.
Choice B reason: Applying moisturizer to dry areas of skin is an effective intervention to prevent skin injury. This is because dry skin is more prone to cracking, peeling, or tearing. The nurse should use a hypoallergenic moisturizer and apply it to the skin after cleansing and drying. The nurse should also avoid using products that contain alcohol, fragrances, or dyes on the skin.
Choice C reason: Using a Hoyer lift for all transfers is an effective intervention to prevent skin injury. This is because a Hoyer lift is a mechanical device that helps to lift and move the client safely and comfortably. It reduces the friction and shear on the skin by lifting the client off the bed surface and avoiding any sliding or dragging. It also prevents the nurse from injuring themselves by lifting the client manually.
Choice D reason: Massaging the client’s reddened shoulders and heels is not an effective intervention to prevent skin injury. In fact, this may worsen the skin injury by increasing the pressure and damage to the tissues. The nurse should avoid massaging any areas that are reddened, swollen, or blistered, as these are signs of pressure ulcers. The nurse should instead relieve the pressure by repositioning the client or using pressurerelieving devices, such as pillows, foam pads, or air mattresses.
Choice E reason: Repositioning the client once per shift is not an effective intervention to prevent skin injury. This is because repositioning the client once per shift is not frequent enough to prevent the development of pressure ulcers. Pressure ulcers are caused by prolonged pressure on the skin that reduces the blood flow and oxygen to the tissues. The nurse should reposition the client at least every 2 hours or more often if needed, depending on the client's condition and risk factors.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the highest risk client because surgery can cause trauma, blood loss, and infection, which can weaken the immune system and increase the susceptibility to complications. The immune system is the body's defense mechanism that protects against foreign invaders, such as bacteria, viruses, or fungi. Surgery can damage the skin and tissues, which are the first line of defense, and cause inflammation, which can impair the function of the white blood cells, which are the second line of defense. The nurse should monitor the client's vital signs, wound healing, and signs of infection and administer antibiotics, fluids, and pain medication as ordered.
Choice B reason: This is not the highest risk client, but it is a moderate risk client because extreme anxiety can cause stress, which can affect the immune system and increase the vulnerability to illness. Stress is the body's response to a perceived threat or challenge, which can activate the sympathetic nervous system and the hypothalamicpituitaryadrenal (HPA) axis. Stress can cause the release of hormones, such as cortisol and adrenaline, which can suppress the immune system and reduce the production and activity of the white blood cells. The nurse should assess the client's anxiety level and provide coping strategies, such as relaxation, breathing, or counseling.
Choice C reason: This is not the highest risk client, but it is a low risk client because awaiting surgery can cause anxiety, which can affect the immune system and increase the vulnerability to illness. However, the client's anxiety level may not be as high as the client with extreme anxiety, and the client's immune system may not be as compromised as the client who has just had surgery. The nurse should assess the client's anxiety level and provide education, reassurance, and support.
Choice D reason: This is not the highest risk client, but it is a low risk client because delivering a baby can cause blood loss, hormonal changes, and fatigue, which can affect the immune system and increase the risk of infection. However, the client's immune system may not be as compromised as the client who has just had surgery, and the client may have some protection from the antibodies that are passed from the mother to the baby through the placenta and breast milk. The nurse should monitor the client's vital signs, lochia, and signs of infection and provide hygiene, nutrition, and rest.
Correct Answer is B
Explanation
Choice A reason: Nociceptive pain is not the type of pain that the client is experiencing. Nociceptive pain is caused by the stimulation of nociceptors, which are sensory receptors that detect tissue damage or potential harm. Nociceptive pain is usually localized, sharp, throbbing, or aching. It is associated with injuries such as cuts, burns, sprains, or fractures. The client's pain is not caused by any tissue damage or harm in the distal part of the amputated limb, as there is no tissue left there.
Choice B reason: Neuropathic pain is the type of pain that the client is experiencing. Neuropathic pain is caused by the damage or dysfunction of the nervous system, such as the peripheral nerves, the spinal cord, or the brain. Neuropathic pain is usually chronic, burning, shooting, or tingling. It is associated with conditions such as diabetes, shingles, stroke, or amputation. The client's pain is caused by the disruption of the nerve signals from the amputated limb, which creates a phantom sensation of pain in the missing part.
Choice C reason: Cutaneous pain is not the type of pain that the client is experiencing. Cutaneous pain is caused by the stimulation of the cutaneous receptors, which are sensory receptors that detect touch, temperature, or pressure on the skin. Cutaneous pain is usually superficial, brief, or pricking. It is associated with stimuli such as pinching, scratching, or cold. The client's pain is not caused by any touch, temperature, or pressure on the skin of the distal part of the amputated limb, as there is no skin left there.
Choice D reason: Visceral pain is not the type of pain that the client is experiencing. Visceral pain is caused by the stimulation of the visceral receptors, which are sensory receptors that detect stretch, inflammation, or ischemia in the internal organs. Visceral pain is usually deep, dull, or cramping. It is associated with conditions such as appendicitis, pancreatitis, or bowel obstruction. The client's pain is not caused by any stretch, inflammation, or ischemia in the internal organs of the distal part of the amputated limb, as there are no organs left there.
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