Because thin skin and lack of subcutaneous fat predisposes the older adult to pressure injuries, the nurse alters the care plan to include turning the bedfast patient how often?
Each evening
Once every shift
Every 4 hours
Every 2 hours
The Correct Answer is D
A. Each evening: Turning the patient only once per day is insufficient to prevent pressure injuries.
B. Once every shift: This is also inadequate as it does not provide the frequent repositioning necessary to prevent pressure injuries.
C. Every 4 hours: While better than every shift, every 4 hours may still not be frequent enough to prevent pressure injuries in at-risk patients.
D. Every 2 hours: Frequent repositioning, such as every 2 hours, is essential for pressure injury prevention in bedfast patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The patient has decreased perceptions: This is a sign of panic anxiety, not necessarily severe anxiety.
B. The patient has increased motivation: Increased motivation is associated with mild to moderate anxiety.
C. The patient has a feeling of impending doom: This is a hallmark of severe anxiety, characterized by intense fear and a sense of catastrophic events.
D. The patient could cause harm to self or others: This is more indicative of panic or extreme anxiety with loss of control.
Correct Answer is A
Explanation
A. Pityriasis rosea typically starts with a single, larger "herald patch" followed by a rash with smaller, oval spots. The described pattern is characteristic of this condition.
B. Herpes zoster virus or shingles, usually presents with vesicular lesions in a dermatomal distribution, rather than scattered oval spots.
C. Herpes simplex type 1 generally causes oral lesions or cold sores, not the body rash described.
D. Impetigo contagiosa is a bacterial infection that typically causes honey-colored crusted sores and is not described as having a herald patch or oval spots.
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