A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?
Massage the client’s bony prominences.
Keep the head of the bed elevated.
Reposition the client at least every 2 hr.
Keep the client’s skin moist.
The Correct Answer is C
A. Massage the client’s bony prominences:
Massaging bony prominences is generally not recommended for individuals at risk for pressure ulcers. Massage can increase friction and shear forces on the skin, which may contribute to skin damage rather than prevent it. Gentle, careful handling of the skin is preferable.
B. Keep the head of the bed elevated:
While elevating the head of the bed may be appropriate for certain medical conditions, it is not a primary preventive measure for pressure ulcers. In fact, keeping the head of the bed elevated continuously can contribute to pressure on the sacrum and coccyx, increasing the risk of pressure ulcers in those areas.
C. Reposition the client at least every 2 hr:
Regular repositioning is a crucial preventive measure for pressure ulcers. Repositioning helps redistribute pressure, improves blood flow to vulnerable areas, and reduces the risk of skin breakdown.
D. Keep the client’s skin moist:
While maintaining skin moisture is important to prevent dryness and cracking, excessive moisture can contribute to skin breakdown. The emphasis should be on keeping the skin clean and dry, with the use of moisturizers applied judiciously to prevent excessive dryness.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Limit potassium-rich foods in the diet.
Limiting potassium is not a typical dietary modification for Cushing's disease. Potassium levels are usually affected in conditions such as Addison's disease, where there is a deficiency of cortisol. In Cushing's disease, the focus is more on sodium balance.
B. Decrease sodium intake.
This is the correct choice. Decreasing sodium intake is a dietary modification relevant to individuals with Cushing's disease. Excessive cortisol production can lead to sodium and water retention, and reducing sodium intake helps manage fluid balance.
C. Increase calorie intake.
While weight gain is a common symptom in individuals with Cushing's disease, simply increasing calorie intake may not be the most specific or appropriate dietary modification. Attention to overall dietary balance and specific components like sodium is more relevant.
D. Consume more calories from carbohydrates than protein.
The macronutrient composition of the diet (carbohydrates vs. protein) is not a specific consideration for individuals with Cushing's disease. The focus is more on overall dietary balance and addressing sodium intake.
Correct Answer is A
Explanation
A. “Increase your caloric intake by eating foods high in protein.”
This is the appropriate choice. Increasing caloric intake with high-protein foods can help meet nutritional needs for individuals with Crohn's Disease, especially if malabsorption is a concern.
B. “Include fresh fruits and vegetables at each meal.”
While fresh fruits and vegetables are generally healthy, they may exacerbate symptoms in some individuals with Crohn's Disease, especially during flare-ups. It may be advisable to choose cooked or processed fruits and vegetables to minimize irritation.
C. “Maintain your weight by eating high-fat foods.”
This statement is not advisable. High-fat foods can contribute to symptoms such as cramping and diarrhea in individuals with Crohn's Disease. A well-balanced diet with an appropriate mix of nutrients is generally recommended.
D. “Drink whole milk to ensure adequate calcium intake.”
This statement is not advisable without considering individual tolerance. Whole milk is high in fat and may be difficult to digest for some individuals with Crohn's Disease. Additionally, if lactose intolerance is present, it may worsen symptoms. Alternative sources of calcium may need to be considered.
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