A nurse educator is working with the staff to decrease skin tissue injuries to clients on the medical surgical unit. Which of the following practices will decrease friction injuries?

instruct the client to dig their heels into the bed to push themselves upwards.

Assist the client with a trapeze to raise their body while staff assists with repositioning

Have two to three staff members pull the client up in bed when needed.

Elevate the head of the bed 90° for bedridden clients.

Answer and Explanation

The Correct Answer is B

A. Instruct the client to dig their heels into the bed to push themselves upwards: This increases friction on the heels, which can lead to skin breakdown.

B. Assist the client with a trapeze to raise their body while staff assists with repositioning. Using a trapeze allows the client to lift themselves slightly off the bed, reducing the friction and shear forces that can cause skin injuries during repositioning.

C. Have two to three staff members pull the client up in bed when needed: This increases the risk of friction injuries, especially if the client is not lifted properly.

D. Elevate the head of the bed 90° for bedridden clients: High elevation of the bed can increase the risk of shear injuries due to sliding down in bed.

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Correct Answer is ["A","B","C","D"]

Explanation

A. Mood changes: Deficiency can cause neurological changes, including depression and mood swings.

B. Mobility challenges: Neuropathy and muscle weakness can lead to mobility issues.

C. Shortness of breath: Anemia from B12 deficiency reduces oxygen delivery, causing dyspnea.

D. Visual deficit: Neurological impairment from B12 deficiency can affect the optic nerve, leading to visual disturbances.

E. Sleep disturbance: This is not a typical manifestation of B12 deficiency and is more likely related to other factors.

A. Electrolyte abnormalities B. Altered hemoglobin ATC C. Psychological distress D. Fluid volume overload

Correct Answer is C

Explanation

A. Electrolyte abnormalities - These are not typically a direct complication of chronic wounds unless they are associated with severe infections or extensive fluid loss, which is uncommon.

B. Altered hemoglobin A1C - While chronic wounds are common in diabetics, the wound itself does not directly alter hemoglobin A1C; this test measures long-term blood glucose control.

C. Psychological distress - Chronic wounds can lead to significant emotional and psychological stress due to prolonged treatment, appearance issues, and limitations in activities.

D. Fluid volume overload - This is not a direct complication of chronic wounds. Chronic wounds might cause fluid loss due to exudate, but not fluid overload.

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A nurse educator is working with the staff to decrease skin tissue injuries to clients on the medical surgical unit. Which of the following practices will decrease friction injuries?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","C","D"]

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Correct Answer is C

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