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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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Drink 3L of fluid every day

Drinking adequate fluids, especially water, is one of the most effective ways to prevent kidney stones. Fluids dilute the substances in urine that lead to stones. For someone with a history of kidney stones, drinking about 3 liters of water each day can help prevent stone formation¹².

Choice B reason: Take 3,000 mg of vitamin C daily

High doses of vitamin C can increase the risk of kidney stones as the body converts vitamin C into oxalate, which can then form stones. Therefore, taking 3,000 mg of vitamin C daily is not recommended for individuals prone to calcium oxalate stones².

Choice C reason: Restrict calcium intake to one serving per day

Contrary to what might seem intuitive, restricting calcium intake is not generally advised for preventing calcium oxalate stones. Adequate dietary calcium can help reduce the amount of oxalate being absorbed by the body, thus lowering the risk of stone formation. It's important to consume calcium-rich foods in moderation and not to restrict them severely.

Choice D reason: Eat 12 oz of animal protein daily

A high intake of animal protein can increase the risk of kidney stones in susceptible individuals. Animal protein can increase calcium and oxalate levels in urine and reduce levels of citrate, a substance that prevents stones. Therefore, it's recommended to limit animal protein intake rather than consume large amounts.

A. Clients with skin traction have more mobility than those with skeletal traction. B. Clients with skin traction have more discomfort than those with skeletal traction. C. Skeletal traction is more appropriate than skin traction for reducing a fracture. D. Skeletal traction has less risk for infection than skin traction.

Correct Answer is C

Explanation

Choice A reason:

Skin traction is indeed less restrictive than skeletal traction, allowing for more mobility. It is applied using bandages or adhesive material to the skin, which can be removed or adjusted more easily than the pins or screws used in skeletal traction. This type of traction is typically used for short-term treatment before surgery or when the injury is less severe.

Choice B reason:

Discomfort levels can vary depending on the individual and the specific circumstances of the traction. However, skin traction is generally considered to be less painful than skeletal traction because it is less invasive and applies less force. Skeletal traction, which involves the insertion of pins or wires directly into the bone, is likely to cause more discomfort due to the invasive nature of the procedure.

Choice C reason:

Skeletal traction is more appropriate for reducing fractures, especially in cases where a greater force is needed to align the bones. It involves the surgical insertion of pins or wires directly into the bone, allowing for a stronger and more stable pull that is necessary for the realignment of complex fractures.

Choice D reason:

Skeletal traction carries a higher risk of infection compared to skin traction because it is more invasive. The insertion of pins or wires into the bone creates a potential entry point for bacteria, which can lead to infection at the site of insertion.

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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.)

Choice A reason:

Choice B reason:

Choice C reason:

Choice D reason:

Choice E reason:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is discussing the differences between skeletal and skin traction with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding?

Correct Answer is C

Explanation

A nurse is reviewing the laboratory report of a client's most recent Pap smear that indicates moderately abnormal cervical cells were present. Based on the description of the cells, which of the following changes of precancerous cell growth to the client's cervix should the nurse identify?

A nurse is reviewing the medication administration records of four clients who have a prescription for morphine PRN. Which of the following findings should the nurse identify as a contraindication to this medication?

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

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