A nurse is caring for a client who is it at risk for a pressure injury. Which of the following actions should the nurse take?

Keep the head of the client’s bed elevated to 45

Provide the client with a high-calorie diet.

Massage the client’s bony prominences.

Reposition the client every 4 hr.

Answer and Explanation

The Correct Answer is B

A) Keep the head of the client’s bed elevated to 45 degrees:
Elevating the head of the bed to 45 degrees can actually increase the risk of pressure injuries, particularly in clients who are already at risk. This position can cause shearing forces and increase pressure on areas such as the sacrum, heels, and hips, making it more likely for pressure ulcers to develop.

B) Provide the client with a high-calorie diet:
A high-calorie diet is important for clients at risk of pressure injuries because adequate nutrition supports skin integrity and wound healing. Clients at risk for pressure injuries often have compromised nutritional status, and providing sufficient calories, protein, and other nutrients helps improve tissue regeneration and resilience. A high-calorie, high-protein diet helps prevent further breakdown of the skin and supports the healing process for any existing wounds.

C) Massage the client’s bony prominences:
Massaging bony prominences, such as the heels, elbows, and sacrum, is not recommended because it can cause tissue damage and increase the risk of pressure injury. Instead, the focus should be on minimizing pressure on these areas and using appropriate methods to redistribute pressure, such as repositioning the client or using pressure-relieving devices.

D) Reposition the client every 4 hours:
Repositioning the client every 4 hours may not be frequent enough for those at high risk for pressure injuries. For individuals who are immobile or at high risk, repositioning should typically occur at least every 2 hours to alleviate pressure on vulnerable areas of the body.

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Correct Answer is A

Explanation

A) Cataracts:
A cloudy, opaque area over the lens of the eye is a classic sign of cataracts. Cataracts occur when the lens of the eye becomes cloudy or opaque, leading to blurry vision and, in some cases, eventual blindness if left untreated. Cataracts typically develop slowly and can be caused by aging, injury, or other conditions like diabetes. Symptoms include difficulty seeing at night, glare, and a decrease in color intensity.

B) Diabetic retinopathy:
Diabetic retinopathy is a complication of diabetes that affects the blood vessels of the retina. It leads to vision problems such as blurred vision, floaters, and even blindness. However, it is characterized by damage to the retina, not cloudiness or opacity over the lens.

C) Macular degeneration:
Macular degeneration affects the macula, the part of the retina responsible for central vision. It leads to a loss of central vision, causing difficulty with tasks like reading or recognizing faces. There is often blurriness or distortion in the center of the visual field.

D) Glaucoma:
Glaucoma is a group of eye conditions that lead to damage to the optic nerve often due to high intraocular pressure. It can result in peripheral vision loss and, if untreated, can lead to blindness. However, glaucoma does not cause a cloudy, opaque lens but rather affects the optic nerve and peripheral vision.

A. Muscle mass B. Bone density C. Joint flexibility D. Muscle strength

Correct Answer is C

Explanation

A) Muscle mass:
Passive range of motion (ROM) exercises do not directly increase muscle mass. These exercises primarily help maintain joint function and flexibility rather than build muscle tissue, which requires active resistance exercises and strength training.

B) Bone density:
While weight-bearing activities can help improve bone density, passive ROM exercises do not have a significant impact on bone density. Passive ROM helps preserve joint function and flexibility but does not address the strengthening of bones.

C) Joint flexibility:
Passive ROM exercises are specifically designed to improve and maintain joint flexibility. These exercises involve the nurse or caregiver moving the client’s joints through their full range of motion without the client’s active participation. The goal is to maintain or increase the joint's flexibility and prevent stiffness, especially in patients who are unable to move their limbs actively, such as those who have had a stroke.

D) Muscle strength:
Passive ROM does not increase muscle strength because the client is not actively engaging their muscles. Muscle strength is built through active movements or resistance exercises, where the client’s muscles work against a force. Passive ROM helps maintain joint mobility, not muscle strength.

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A nurse is caring for a client who is it at risk for a pressure injury. Which of the following actions should the nurse take?

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