A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)
Massage over erythematous bony prominences.
Minimize skin exposure to moisture.
Use pillows to keep heels off the bed surface.
Implement a turning schedule every 4 hours.
Keep the client's skin dry with powder.
Correct Answer : B,C
The correct answer is b. Minimize skin exposure to moisture and c. Use pillows to keep heels off the bed surface.
Choice A reason:
a. Massage over erythematous bony prominences: This is incorrect because massaging erythematous (reddened) areas can cause further tissue damage and exacerbate skin breakdown.
Choice B reason:
b. Minimize skin exposure to moisture: This is correct. Moisture can lead to skin maceration, increasing the risk of skin breakdown. Keeping the skin dry helps maintain its integrity.
Choice C reason:
c. Use pillows to keep heels off the bed surface: This is correct. Elevating the heels reduces pressure on them, preventing pressure ulcers.
Choice D reason:
d. Implement a turning schedule every 4 hours: This is incorrect. To prevent pressure injuries, turning should be done every 2 hours, not every 4 hours.
Choice E reason:
e. Keep the client’s skin dry with powder: This is incorrect. Powder can cause skin irritation and breakdown.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A reason:
Herpes zoster lesions are indeed contagious if they are draining. The virus can spread through direct contact with the fluid from the blisters. It is crucial to cover the lesions to prevent spreading the virus to others, especially to those who have never had chickenpox or the vaccine.
Choice B reason:
The development of vesicles, which are small fluid-filled blisters, is a hallmark of herpes zoster. These vesicles typically appear in a band-like pattern on one side of the body and are often accompanied by pain, itching, or tingling before they are visible.
Choice C reason:
Postherpetic neuralgia is a condition where the pain persists in the area of the herpes zoster rash even after the lesions have healed. This can last for weeks, months, or even years and is more common in older adults.
Choice D reason:
Herpes zoster itself is not spread like chickenpox. It occurs when the varicella-zoster virus, which has been lying dormant in the nerve cells, reactivates. While it is possible for someone who has never had chickenpox to develop chickenpox after direct contact with a shingles rash, herpes zoster is not "easily spread" to others in the same way that chickenpox is.
Correct Answer is D
Explanation
Choice A reason:
Tennis may not be the best recommendation for someone with low back pain. The sport requires quick lateral movements, sudden stops, and starts, as well as repetitive twisting motions that can exacerbate back pain. While it provides good general exercise, the high-impact nature of tennis and the strain it puts on the back could potentially worsen the client's condition.
Choice B reason:
Canoeing involves repetitive rowing actions that can strain the lower back, especially if the individual does not use proper form. The seated position in a canoe may also put additional pressure on the lower back. Therefore, it might not be the most suitable activity for someone experiencing low back pain.
Choice C reason:
Rowing, similar to canoeing, can place stress on the lower back due to the repetitive motion and the need for strong engagement of the core muscles. If not performed with proper technique, rowing could lead to increased back pain and is not typically recommended for those with existing low back issues.
Choice D reason:
Swimming is often recommended for individuals with low back pain because it is a low-impact exercise that does not put additional stress on the spine. The buoyancy of the water supports the body, reducing the load on the back while allowing for a full range of motion. Swimming can help strengthen the back muscles and improve flexibility, making it a suitable activity for managing low back pain.
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