A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity?

Use warm water when bathing the client.

Place a donut-shaped cushion in the client's chair.

Massage reddened areas over bony prominences.

Maintain the client in high-Fowler's position.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Use warm water when bathing the client.

Choice A rationale:

Using warm water when bathing helps maintain skin integrity by ensuring the skin is clean without causing excessive dryness or irritation. Warm water is gentle on the skin and helps in maintaining its natural moisture balance.

Choice B rationale:

Placing a donut-shaped cushion in the client’s chair is not recommended as it can cause pressure points and restrict blood flow, potentially leading to pressure ulcers.

Choice C rationale:

Massaging reddened areas over bony prominences is not advisable because it can cause further damage to already compromised skin and increase the risk of pressure ulcers.

Choice D rationale:

Maintaining the client in high-Fowler’s position for extended periods can increase pressure on the sacral area, leading to pressure ulcers. It is important to regularly reposition the client to alleviate pressure.

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Correct Answer is D

Explanation

The correct answer is choiced. "Describe your concerns about sleeping to me.".

Choice A rationale:

While offering frequent checks can provide some reassurance, it does not address the underlying fear the client is experiencing. It is more of a practical solution rather than a therapeutic one.

Choice B rationale:

Agreeing with the client’s fear without offering a solution or support can increase their anxiety. It is important to acknowledge their feelings but also to provide comfort and reassurance.

Choice C rationale:

Offering sleeping medication might help the client fall asleep, but it does not address the root cause of their fear. It is important to understand and address the client’s concerns directly.

Choice D rationale:

Asking the client to describe their concerns is a therapeutic approach that encourages them to express their fears.This allows the nurse to understand the client’s perspective and provide appropriate emotional support.

A. Fluid overload. B. Diarrhea. C. Headache. D. Difficulty voiding.

Correct Answer is C

Explanation

The correct answer is choice C. Headache.

Choice A rationale:

Fluid overload is not a potential adverse effect of a lumbar puncture. A lumbar puncture involves the removal of cerebrospinal fluid (CSF) from the spinal canal, which wouldn't lead to fluid overload. This choice is not relevant to the procedure.

Choice B rationale:

Diarrhea is not a common adverse effect of a lumbar puncture. The procedure involves accessing the spinal canal and collecting CSF, which is not directly connected to the gastrointestinal system. Diarrhea is unrelated to the procedure.

Choice C rationale:

Headache is a potential adverse effect of a lumbar puncture. This is caused by the leakage of cerebrospinal fluid (CSF) through the puncture site, leading to a decrease in CSF pressure. This drop in pressure can cause a headache, particularly when the client sits or stands up. The headache is often described as severe and may be accompanied by neck pain and sensitivity to light. It usually resolves within a few days but can be managed with pain relief medications and plenty of fluids.

Choice D rationale:

Difficulty voiding is not a common adverse effect of a lumbar puncture. The procedure involves the lower back and spinal canal, and it doesn't directly affect the urinary system. This choice is unrelated to the procedure and its potential complications.

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A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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