A nurse is caring for a client who is malnourished with poor skin integrity. The nurse should utilize which type of dressing to protect the client's bony prominences?

Foam

Non-adherent

Ace bandage

Hydrocolloid

Answer and Explanation

The Correct Answer is B

A. Foam:
Explanation: Foam dressings are highly absorbent and provide cushioning and protection to wounds. They are suitable for wounds with moderate to heavy drainage. While foam dressings are excellent for wound exudate management, they are not specifically designed for protecting bony prominences or areas with poor skin integrity.

B. Non-adherent:
Explanation: Non-adherent dressings are made from materials that do not stick to the wound bed. They are ideal for fragile skin, bony prominences, or superficial wounds where minimizing trauma during dressing changes is important. Non-adherent dressings are often used for preventing further skin damage in malnourished clients with poor skin integrity.

C. Ace bandage:
Explanation: Ace bandages, or elastic bandages, are primarily used for providing compression and support to injured joints or muscles. They are not designed for protecting bony prominences or fragile skin areas. Using an Ace bandage on a bony prominence could lead to pressure points and skin damage.

D. Hydrocolloid:
Explanation: Hydrocolloid dressings are absorbent and form a gel-like barrier when they come into contact with wound exudate. They provide a moist environment that supports healing and autolytic debridement. Hydrocolloid dressings are suitable for wounds with light to moderate drainage. While they are beneficial for certain wounds, they are not specifically indicated for protecting bony prominences in malnourished clients.

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Correct Answer is A

Explanation

Explanation:
A. Promptly inform the primary provider:
Explanation: Compartment syndrome is a medical emergency that requires immediate intervention. If a nurse suspects compartment syndrome due to symptoms like severe unrelieved pain, absent pulses, and pale extremities, the most appropriate action is to promptly inform the primary healthcare provider. The provider can assess the situation, order necessary diagnostic tests, and potentially arrange for emergent interventions like fasciotomy to relieve compartment pressure.

B. Reassess the client's neurovascular status in 15 minutes:
Explanation: Waiting for 15 minutes to reassess the client's neurovascular status is not appropriate in this situation. Compartment syndrome can progress rapidly, leading to irreversible tissue damage within a short time frame. Delaying assessment and intervention can result in significant complications.

C. Warm the client's foot and determine whether circulation improves:
Explanation: Warming the foot is not appropriate in this context. Compartment syndrome is caused by increased pressure within the muscle compartment, leading to compromised circulation. Warming the foot will not address the underlying issue of elevated compartment pressure and can potentially worsen the condition by dilating blood vessels and increasing pressure further.

D. Reposition the client with the affected foot dependent:
Explanation: Repositioning the client with the affected foot dependent is contraindicated in compartment syndrome. Elevating the limb can worsen the condition by further restricting blood flow. The limb should be kept at or slightly below the level of the heart to maintain adequate perfusion until medical intervention can be initiated.

A. Stretching exercises B. Riding a bicycle C. Walking briskly D. High-impact aerobics

Correct Answer is A

Explanation

A. Stretching exercises:

Stretching exercises involve gently elongating muscles and tendons, promoting flexibility and range of motion. For individuals with osteoporosis, stretching exercises can improve balance and reduce the risk of falls, which is crucial as osteoporosis weakens bones and makes individuals more prone to fractures.
B. Riding a bicycle:

Bicycling is a low-impact cardiovascular exercise that is easy on the joints. It can help improve cardiovascular health, but it might not specifically address the balance and flexibility issues often associated with osteoporosis. However, it's a good option for overall fitness and joint health.
C. Walking briskly:

Brisk walking is an excellent low-impact aerobic exercise. It improves cardiovascular health, strengthens muscles, and aids in weight management. Walking can be adapted to various fitness levels, making it a suitable exercise for many older adults. While it doesn't specifically focus on flexibility, it promotes overall health and well-being.
D. High-impact aerobics:

High-impact aerobics involve activities like jumping, running, or intense dancing. These exercises can stress the bones and joints, potentially leading to injuries, especially for individuals with osteoporosis. High-impact exercises are generally discouraged for people with osteoporosis due to the increased risk of fractures.

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A nurse is caring for a client who is malnourished with poor skin integrity. The nurse should utilize which type of dressing to protect the client's bony prominences?

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