A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk of a friction and shear injury?

Postpone daily bed bath

Elevate the client’s head of the bed to 45 degrees

Caregiver independently slides the client up in bed

Use a mechanical lift to reposition the client every 2 hours

Answer and Explanation

The Correct Answer is D

Choice A reason: Postponing daily bed bath is not appropriate for reducing the risk of a friction and shear injury. Bed bath is a hygiene measure that helps to keep the skin clean and dry and prevent infection. Friction and shear are caused by the rubbing and pulling of the skin against the bed surface, not by the bed bath itself.

Choice B reason: Elevating the client’s head of the bed to 45 degrees is not appropriate for reducing the risk of a friction and shear injury. In fact, this may increase the risk as the client may slide down the bed due to gravity and cause more friction and shear on the skin. The head of the bed should be kept at the lowest possible angle, preferably less than 30 degrees, unless contraindicated by the client’s condition.

Choice C reason: Caregiver independently slides the client up in bed is not appropriate for reducing the risk of a friction and shear injury. This may cause more damage to the skin as the caregiver may exert excessive force and drag the client’s skin along the bed surface. The caregiver should use a draw sheet or a slide board to lift and reposition the client with the help of another person.

Choice D reason: Use a mechanical lift to reposition the client every 2 hours is the most appropriate intervention for reducing the risk of a friction and shear injury. A mechanical lift is a device that helps to transfer and reposition 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 caregiver from injuring themselves by lifting the client manually. The client should be repositioned every 2 hours to relieve the pressure on the skin and prevent pressure ulcers.

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Correct Answer is D

Explanation

Choice A reason: The client instills the prescribed number of eye drops into the conjunctival sac is a correct action, because it ensures that the medication reaches the eye surface and does not spill out. The conjunctival sac is the space between the eyelid and the eyeball.

Choice B reason: The client washes her hands before instilling the eye drops is a correct action, because it prevents the introduction of microorganisms or foreign substances into the eye. Hand hygiene is an essential infection control measure.

Choice C reason: The client sets the cap to the eye drop container down in a manner that does not contaminate it is a correct action, because it preserves the sterility of the eye drop solution and prevents crosscontamination. The cap should be placed on a clean surface with the inner side facing up.

Choice D reason: The client touches the administration dropper to the eye is an incorrect action, because it can cause injury, infection, or contamination of the eye drop solution. The administration dropper should be held close to the eye, but not touch it.

A. "If I am reexposed to HIV, the progression to AIDS may be faster." B. "My diet does not influence the progression of HIV to AIDS." C. "If I practice meditation, I may develop AIDS faster." D. "Sexually transmitted infections will not make AIDS develop faster."

Correct Answer is A

Explanation

Choice A reason: This is the correct statement because it reflects the fact that reexposure to HIV can increase the viral load and accelerate the decline of the immune system. HIV is a virus that infects and destroys the CD4 cells, which are the white blood cells that help fight infections. AIDS is the final stage of HIV infection, when the CD4 count falls below 200 cells/mm3 or the client develops an opportunistic infection. The progression from HIV to AIDS can vary from person to person, depending on several factors, such as viral strain, genetic factors, treatment adherence, and coinfections. Reexposure to HIV can expose the client to a different or more aggressive strain of the virus, which can overwhelm the immune system and hasten the development of AIDS.

Choice B reason: This is an incorrect statement because it ignores the role of nutrition in maintaining the health and function of the immune system. Diet can influence the progression of HIV to AIDS by affecting the client's weight, energy, metabolism, and susceptibility to infections. The client should eat a balanced and varied diet that provides adequate calories, protein, vitamins, minerals, and fluids. The client should also avoid foods that can cause diarrhea, dehydration, or food poisoning, which can worsen the symptoms and complications of HIV infection.

Choice C reason: This is an incorrect statement because it contradicts the evidence that shows that meditation can have positive effects on the psychological and physiological wellbeing of people living with HIV. Meditation is a mindbody practice that involves focusing attention on the present moment, breathing, and relaxation. Meditation can help the client cope with stress, anxiety, depression, and pain, which are common challenges for people living with HIV. Meditation can also improve the immune system function by reducing inflammation, oxidative stress, and cortisol levels, which can slow down the progression of HIV to AIDS.

Choice D reason: This is an incorrect statement because it overlooks the impact of sexually transmitted infections (STIs) on the course of HIV infection. STIs can increase the risk of transmitting and acquiring HIV by causing ulcers, inflammation, or bleeding in the genital area, which can facilitate the entry and exit of the virus. STIs can also increase the viral load and decrease the CD4 count, which can speed up the progression of HIV to AIDS. The client should practice safe sex by using condoms, getting tested and treated for STIs, and informing their sexual partners about their HIV status.

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A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk of a friction and shear injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing education to a client regarding the administration of eye drops. Which of the following actions indicates the need for further client education?

Correct Answer is D

Explanation

This is the edited text:What statement by the client indicates a correct understanding of the timing of progression of human immunodeficiency virus (HIV) to acquired immunodeficiency syndrome (AIDS)?

Correct Answer is A

Explanation

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