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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Keep the prosthesis in direct contact with the residual limb.

This statement is incorrect. Prosthetic care typically involves using a liner or sock between the residual limb and the prosthesis. This helps to provide cushioning, absorb sweat, and reduce friction, contributing to comfort and preventing skin irritation.

B. Apply a moisturizing lotion or oil to the stump daily.

Moisturizing the skin on the residual limb is generally advisable to prevent dryness and irritation. However, it's crucial to ensure that the skin is completely dry before attaching the prosthesis. Moisturizing can help maintain skin health and comfort.

C. Dry the prosthesis socket completely before applying it to the limb.

This statement is correct. Ensuring that the prosthesis socket is thoroughly dry before application is crucial to prevent skin irritation and ensure a secure fit. Moisture between the skin and the prosthesis can contribute to discomfort and skin-related issues.

D. Expect some skin irritation from the prosthesis.

While it is common to experience minor skin irritation initially as the individual adjusts to the prosthesis, persistent or severe irritation should be addressed. The goal is to achieve a proper fit and minimize skin-related problems through appropriate care and adjustments.

A. Limit potassium rich foods in the diet. B. Decrease sodium intake. C. Increase calorie intake. D. Consume more calories from carbohydrates than protein.

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.

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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?

Nursing Test Bank

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