A nurse is providing teaching to a client about reducing the adverse effects of immobility.

Which of the following statements by the client indicates an understanding of the teaching?

"I will perform ankle and knee exercises every hour."

"I will have my partner help me change positions every 4 hours."

"I will remove my antiembolic stockings while I am in bed."

"I will hold my breath when rising from a sitting position."

Answer and Explanation

The Correct Answer is A

A.   Regular ankle and knee exercises help prevent muscle atrophy due to immobility.
B.   Changing positions every 4 hours is helpful, but more frequent movement is recommended.
C.   Antiembolic stockings should be worn when immobile to prevent blood clots.
D.   Holding breath during movement doesn't contribute to reducing adverse effects of immobility.

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Correct Answer is D

Explanation

A. Loosening the bed linensmay not have a significant effect on the client's pain level, and may increase the risk of infection or further injury to the pressure ulcer.
B. Massaging the sacrum in the context of a pressure injury might exacerbate the condition and isn't recommended.
C. Providing bright lights might not specifically address the acute pain from the pressure injury.
D. Music therapy is a nonpharmacological intervention that can help reduce pain perception, anxiety, and stress in clients who have acute pain. Music can also provide distraction, relaxation, and comfort to the client.

A. Massage the client's bony prominences. B. Ensure the client's heels are not touching the mattress. C. Raise the head of the client's bed to a 60° angle. D. Reposition the client every 4 hr.

Correct Answer is B

Explanation

A. Massaging bony prominences can actually increase the risk of pressure injury by causing friction and shearing forces on the skin.
B. Elevating the heels reduces the pressure on the skin and improves blood circulation.
C. Raising the head of the bed to a 60° angle doesn't directly address pressure injury prevention and might even increase pressure on certain areas.
D. Repositioning the client every 4 hours is not frequent enough to prevent pressure injuries.

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A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological interventions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client's risk of developing a pressure injury?

Correct Answer is B

Explanation

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A nurse is providing teaching to a client about reducing the adverse effects of immobility.

Which of the following statements by the client indicates an understanding of the teaching?