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
Explanation
Choice A reason:
Thyroid hormones, particularly when taken in excess, can lead to bone loss and increase the risk of osteoporosis. This is because thyroid hormones can stimulate bone resorption, which is the process where bone tissue is broken down and the minerals are released into the bloodstream.
Choice B reason:
NSAIDs (Nonsteroidal Anti-Inflammatory Drugs) are not typically associated with an increased risk of osteoporosis. While long-term use of NSAIDs can have various side effects, they do not directly contribute to bone density loss or osteoporosis.
Choice C reason:
Anticoagulants, such as warfarin, have been associated with an increased risk of osteoporotic fractures. However, the evidence is not as strong as it is for other medications like corticosteroids or thyroid hormones.
Choice D reason:
Cardiac glycosides, used to treat heart conditions, have not been shown to be a direct risk factor for osteoporosis. While they affect heart muscle contractions, they do not have a known impact on bone metabolism.
Correct Answer is B
Explanation
Choice A reason:
Testicular torsion is a condition where the spermatic cord becomes twisted, cutting off the blood supply to the testicle. It is not a typical complication following a prostatectomy. Testicular torsion is generally an acute condition that affects younger males and is unrelated to prostate surgery.
Choice B reason:
Erectile dysfunction (ED) is a common complication after prostatectomy. The surgery can damage the nerves and blood vessels that control erections, leading to ED. While nerve-sparing techniques aim to reduce this risk, some degree of erectile dysfunction is still possible after the procedure.
Choice C reason:
Cystitis, which is inflammation of the bladder, can occur after a prostatectomy due to the use of a catheter or as a result of the surgery itself. However, it is not as common or as significant a long-term complication as erectile dysfunction.
Choice D reason:
Paralytic ileus, a temporary cessation of bowel movements, can occur after any abdominal surgery due to the manipulation of the intestines or as a side effect of anesthesia. While it can be a complication of prostatectomy, it is typically resolved within a few days to weeks after surgery.

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