A nurse is contributing to the plan of care for a client who has a spinal cord injury and paralysis.
Which of the following actions should the nurse include in the plan to decrease the client's risk of skin breakdown?

Implement a turning schedule every 4 hr.

Minimize skin exposure to moisture.

Massage erythematous bony prominences.

Keep environmental humidity less than 30%.

Use pillows to keep heels off the bed surface.

Answer and Explanation

Correct Answer : B

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Correct Answer is D

No explanation

A. The client is asleep. B. The client has an elevated blood pressure. C. The client has an increased respiratory rate. D. The client is diaphoretic.

Correct Answer is A

Explanation

Answer is: A. The client is asleep.

Explanation:

- A. The client is asleep. This is the correct answer because a client who is asleep is likely to have less pain than a client who is awake and restless. Opioid narcotics can also cause sedation, which can indicate effective pain relief.
- B. The client has an elevated blood pressure. This is incorrect because an elevated blood pressure can indicate increased pain, stress, anxiety, or other factors that are not related to pain relief. Opioid narcotics can also cause hypotension, which can indicate overdose or adverse effects.
- C. The client has an increased respiratory rate. This is incorrect because an increased respiratory rate can indicate increased pain, anxiety, hypoxia, or other factors that are not related to pain relief. Opioid narcotics can also cause respiratory depression, which can indicate overdose or adverse effects.
- D. The client is diaphoretic. This is incorrect because diaphoresis can indicate increased pain, fever, infection, or other factors that are not related to pain relief. Opioid narcotics can also cause sweating, which can indicate withdrawal or adverse effects.

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A nurse is contributing to the plan of care for a client who has a spinal cord injury and paralysis. Which of the following actions should the nurse include in the plan to decrease the client's risk of skin breakdown?

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Correct Answer is A

Explanation

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A nurse is contributing to the plan of care for a client who has a spinal cord injury and paralysis.
Which of the following actions should the nurse include in the plan to decrease the client's risk of skin breakdown?