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?
Place the client upright on a donut-shaped cushion.
Turn and reposition the client every 15 minutes while sitting.
Apply a moisture-barrier cream to the affected area.
Turn and reposition the client every 3 hours while in bed.
The Correct Answer is B
Choice A rationale: Donut-shaped cushions are contraindicated because they create a ring of high pressure that restricts blood flow to the central area. This can worsen tissue ischemia and accelerate skin breakdown.
Choice B rationale: Clients with paraplegia sitting in a chair should be repositioned every 15 minutes to relieve pressure. Frequent shifts are necessary because sitting exerts higher pressure on the ischial tuberosities than lying down.
Choice C rationale: Moisture-barrier creams are used to protect skin from incontinence or wound drainage. Nonblanchable erythema indicates a stage 1 pressure injury, which requires pressure relief rather than a topical moisture barrier.
Choice D rationale: While in bed, the standard of care is to turn and reposition the client at least every 2 hours. A 3-hour interval is too long and increases the risk of further tissue damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Preferring loose clothing to hide scars indicates an altered body image, as it reflects discomfort with physical changes post-mastectomy. This behavior suggests emotional distress about appearance, a common response to surgical body alterations, making it the correct indicator.
Choice B reason: Joining a support group shows proactive coping and acceptance, not necessarily an altered body image. It reflects social engagement and resilience, not distress about physical changes, making it incorrect for indicating body image concerns.
Choice C reason: Feeling confident about recovery suggests positive adjustment, not an altered body image. Confidence indicates emotional resilience rather than distress about physical appearance post-mastectomy, making this statement incorrect for this concern.
Choice D reason: Planning to resume exercise indicates focus on recovery and health, not body image distress. This proactive attitude reflects physical rehabilitation goals, not emotional concerns about appearance, making it incorrect for altered body image.
Correct Answer is A
Explanation
Choice A reason: Encouraging open communication fosters dialogue, allowing nurses to resolve conflicts directly. This reduces tension and improves teamwork by addressing interpersonal issues, aligning with psychological principles of conflict resolution. Effective communication mitigates misunderstandings, enhancing collaboration in high-stress healthcare environments.
Choice B reason: Assigning an external mediator may help but is premature without trying internal resolution. Encouraging team dialogue leverages existing relationships, fostering cohesion. External mediators may not address unit-specific dynamics, making internal communication a more effective first step in resolving nurse conflicts.
Choice C reason: Mandatory team-building exercises may improve morale but do not directly resolve specific conflicts. Forcing participation can increase resentment if issues persist. Communication-based strategies target root causes, making them more effective for conflict resolution in healthcare teams compared to generic team-building.
Choice D reason: Reassigning nurses to different shifts avoids conflict but disrupts workflow and patient care continuity. It fails to address underlying issues, allowing tensions to persist. Communication-focused approaches promote resolution, maintaining team integrity and collaboration in healthcare settings, unlike reassignment.
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