A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

Assess pressure points every 24 hr.

Turn and reposition the client every 3 hr while in bed.

Teach the client to shift his weight every 15 min while sitting.

Place the client upright ona donut-shaped cushion.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Assess pressure points every 24 hr: Skin assessment should be performed at least every shift or more frequently in high-risk clients. Waiting 24 hours between assessments increases the risk of progression from erythema to ulceration due to unrelieved pressure.

B. Turn and reposition the client every 3 hr while in bed: Clients at risk for pressure injuries should be repositioned at least every 2 hours in bed to promote circulation and reduce tissue ischemia. Extending this interval to 3 hours is inadequate for prevention or healing.

C. Teach the client to shift his weight every 15 min while sitting: Teaching the client to perform weight shifts every 15 minutes reduces pressure on the ischial areas, promoting blood flow and preventing further skin breakdown. This intervention empowers self-care and is a key preventive strategy for wheelchair-bound clients.

D. Place the client upright on a donut-shaped cushion: Donut cushions can impair circulation around the pressure site by concentrating pressure on surrounding tissue, worsening ischemia and tissue damage. Pressure-redistribution cushions or gel pads are safer alternatives.

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Correct Answer is B

Explanation

Rationale:
A. "You can continue to use the diaphragm you used before your pregnancy.": The diaphragm must be refitted after childbirth due to changes in vaginal and cervical anatomy, so continued use without refitting is not recommended.

B. "Place the transdermal birth control patch on your upper outer arm.": The patch should be applied to areas such as the abdomen, buttock, upper torso, or upper outer arm—but not if breastfeeding, as it contains estrogen, which can reduce milk production.

C. "The lactation amenorrhea method is effective for your first year postpartum.": This method is only effective for the first 6 months postpartum, provided the mother is exclusively breastfeeding and has not resumed menses.

D. "You should avoid vaginal spermicides while breastfeeding.": Vaginal spermicides can be used while breastfeeding. They do not affect milk production or the baby. However, they are not as effective as other methods of contraception and are often used in combination with other methods, such as condoms or diaphragms

A. Maintain the head of the bed at a 30 degree angle. B. Administer stool softeners to the client. C. Encourage the client to cough and deep breathe. D. Obtain client vital signs every 8 hr. E. Provide a quiet environment for the client.

Correct Answer is ["A","B","E"]

Explanation

Rationale:
A. Maintain the head of the bed at a 30 degree angle: Elevating the head of the bed promotes venous drainage from the brain and helps lower intracranial pressure (ICP). A 30-degree position optimizes cerebral perfusion without compromising blood flow to the brain tissue.

B. Administer stool softeners to the client: Stool softeners prevent straining during bowel movements, which increases intrathoracic and intracranial pressure. Preventing Valsalva maneuvers helps maintain stable ICP and reduces the risk of secondary brain injury.

C. Encourage the client to cough and deep breathe: Coughing can sharply increase ICP due to the rise in intrathoracic pressure. Clients with elevated ICP should be discouraged from coughing or performing any action that increases pressure in the head.

D. Obtain client vital signs every 8 hr: Clients with increased ICP require frequent monitoring, typically every 1 to 2 hours or continuously, depending on severity. Monitoring only every 8 hours is inadequate and could delay detection of critical changes in neurological status.

E. Provide a quiet environment for the client: Reducing environmental stimuli, such as noise and bright lights, prevents agitation and minimizes fluctuations in ICP. A calm and quiet setting supports cerebral stability and promotes healing.

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A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

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