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 C
Explanation
Choice A reason:
Danazol is a synthetic steroid that is typically used to treat endometriosis and fibrocystic breast disease. It is not indicated for the treatment of benign prostatic hyperplasia (BPH) and could potentially worsen symptoms due to its androgenic effects.
Choice B reason:
Methyltestosterone is an anabolic steroid with androgenic properties, similar to the male hormone testosterone. It is used to treat men with testosterone deficiency. However, it is not used for BPH treatment and, like danazol, could exacerbate BPH symptoms due to its androgenic activity.
Choice C reason:
Finasteride is a 5-alpha reductase inhibitor that is commonly prescribed for the treatment of BPH. It works by inhibiting the conversion of testosterone to dihydrotestosterone (DHT), a hormone that contributes to prostate growth. By reducing DHT levels, finasteride can help shrink the prostate and alleviate urinary symptoms associated with BPH.
Choice D reason:
Fluoxymesterone is another anabolic steroid with testosterone-like effects. It is used to treat conditions associated with a deficiency or absence of endogenous testosterone. It is not suitable for BPH treatment and could potentially worsen the condition due to its androgenic properties.
Correct Answer is D
Explanation
Choice A reason:
Using closed-ended questions when obtaining a health history can be limiting and may not provide the full context of the patient's sexual health risks. Open-ended questions are generally recommended to encourage a more comprehensive discussion about sexual behaviors and risks.
Choice B reason:
A client's reproductive health history is crucial for counseling purposes. It provides insight into potential risks for STIs and helps tailor the counseling to the client's specific needs and circumstances.
Choice C reason:
Referring a client to genetic counseling for having had an STI is not typically necessary. Genetic counseling is more relevant for hereditary conditions and is not a standard part of STI management.
Choice D reason:
Asking about a client's exposure to past or present STIs is essential in STI counseling. It helps assess the client's risk level and informs the necessary prevention and treatment strategies.
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