A nurse is evaluating a nursing student's understanding of positioning clients. Which of the following statements indicates a need for further teaching?
Positioning a client in good body alignment and changing the position regularly (every 3 hours) and systematically are essential aspects of nursing practice.
"Frequent change in position helps to prevent muscle discomfort, undue pressure resulting in pressure ulcers, damage to superficial nerves and blood vessels, and contractures."
"Any position, correct or incorrect, can be detrimental if maintained for a prolonged period."
"For all clients, it is important to assess the skin and provide skin care before and after a position change.
The Correct Answer is A
This statement indicates a need for further teaching because it is not accurate. Positioning a client in good body alignment and changing the position regularly are essential aspects of nursing practice, but the position should be changed more frequently than every 3 hours. It is generally recommended to reposition clients at least every 2 hours to prevent pressure ulcers and other complications. The other options (Frequent change in position helps to prevent muscle discomfort, undue pressure resulting in pressure ulcers, damage to superficial nerves and blood vessels, and contractures; Any position, correct or incorrect, can be detrimental if maintained for a prolonged period; and For all clients, it is important to assess the skin and provide skin care before and after a position change) are accurate statements and do not indicate a need for further teaching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Guided imagery is a mind-body therapy that involves using mental images to help reduce stress and promote relaxation. In this case, the client is picturing themselves lying on a beach with the sounds of waves, the cries of seagulls, and the warmth of the sun to help them relax during periods of stress.
Correct Answer is A
Explanation
The nursing process consists of five phases: assessment, diagnosis, planning, implementation, and evaluation. During the assessment phase, the nurse gathers information about the client's health status and needs. In this scenario, the nurse is conducting a dressing change and notes a new area of skin breakdown. This observation is part of the assessment phase of the nursing process, as the nurse is gathering information about the client's condition. The other phases of the nursing process involve analyzing the information gathered during assessment (diagnosis), developing a plan of care (planning), carrying out interventions (implementation), and evaluating the effectiveness of care (evaluation).
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