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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:
It is essential to dry the prosthesis socket completely before applying it to the limb to prevent any moisture-related issues, such as skin irritation or infection. Moisture can create an environment conducive to bacterial growth and can also cause the prosthesis to slip or not fit properly.

Choice B reason:
While it is important to keep the skin of the stump moisturized, applying lotion or oil immediately before putting on the prosthesis is not advised. Lotions and oils can make the skin slippery, leading to a poor fit of the prosthesis or even causing the prosthesis to slip off. It is better to apply moisturizer at a time when the prosthesis will not be worn for a while, allowing the skin to absorb the lotion fully.

Choice C reason:
The prosthesis should not be in direct contact with the residual limb without proper padding or a liner. Direct contact can lead to pressure sores, skin irritation, and discomfort. Properly fitted socks or liners should be used to cushion the limb and ensure a comfortable, secure fit.

Choice D reason:
While some skin irritation may be expected when first using a prosthesis, persistent irritation is not normal and should be addressed by a healthcare provider. The prosthesis may need to be adjusted, or there may be an issue with the fit or the materials used. Skin irritation should not be accepted as a standard part of using a prosthesis.

A. Arthralgia B. Bradycardia C. Fecal impaction D. Hypertension

Correct Answer is A

Explanation

Choice A reason:
Arthralgia, or joint pain, is a common symptom associated with heterotopic ossification (HO), especially when it occurs near joints. The ectopic bone formation can lead to restricted movement and pain during joint movement.

Choice B reason:
Bradycardia, or a slower than normal heart rate, is not directly associated with HO. While spinal cord injuries can affect autonomic control and potentially lead to bradycardia, it is not a symptom specifically linked to the presence of HO.

Choice C reason:
Fecal impaction may occur in patients with spinal cord injuries due to mobility issues and changes in bowel function, but it is not a direct result of HO. HO does not typically affect bowel movements unless the ossification is in a location that mechanically obstructs the bowel.

Choice D reason:
Hypertension, or high blood pressure, is not a symptom commonly associated with HO. While individuals with spinal cord injuries may experience dysregulation of blood pressure, this is not specifically related to HO.

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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

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A nurse is teaching a client who has a prosthetic limb due to a right below-the-knee amputation about prosthesis and stump care. Which of the following instructions should the nurse include in the teaching?

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