The nurse is providing care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the care plan to help prevent the development of pressure Injuries?

Reposition the client at least every two hours.

Encourage the client to limit fluid intake.

Use a donut-shaped cushion under the client's hips.

Apply a heating pad to the client's back every four hours

Answer and Explanation

The Correct Answer is A

A. Reposition the client at least every two hours. Regular repositioning reduces prolonged pressure on specific areas of the body, which helps prevent the formation of pressure injuries.

B. Encourage the client to limit fluid intake. Adequate hydration is important for skin integrity. Limiting fluid intake could lead to dehydration, increasing the risk for skin breakdown.

C. Use a donut-shaped cushion under the client's hips. Donut-shaped cushions can actually increase pressure around the edges of the cushion and restrict blood flow, which could worsen pressure injury risk.

D. Apply a heating pad to the client's back every four hours. Heat can cause skin damage and may increase the risk of burns. Temperature regulation is important, but heating pads are not recommended for pressure injury prevention.

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Correct Answer is D

Explanation

A. Pain in the neck when the patient flexes their head towards the chest. This describes nuchal rigidity, not Kernig sign.

B. Involuntary flexion of the hips and knees when the neck is flexed. This describes Brudzinski sign, not Kernig sign.

C. Photophobia and headache triggered by bright light. These are symptoms of meningitis, but they are not specific to Kernig sign.

D. Pain and resistance when attempting to extend the patient's leg from a flexed position. A positive Kernig sign is when there is pain and resistance to leg extension from a flexed hip and knee position, indicating meningeal irritation.

A. Deep vein thrombosis B. Restless leg syndrome C. Intermittent claudication D. Varicose veins

Correct Answer is C

Explanation

A. Deep vein thrombosis. Deep vein thrombosis typically causes constant pain, swelling, and redness and does not improve with rest.

B. Restless leg syndrome. Restless leg syndrome is characterized by an uncontrollable urge to move the legs, usually at rest, and is not associated with walking.

C. Intermittent claudication. Intermittent claudication is a common symptom of PAD where muscle pain or cramping occurs during activity and is relieved with rest due to insufficient blood flow.

D. Varicose veins. Varicose veins generally cause aching and swelling rather than pain triggered specifically by walking.

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The nurse is providing care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the care plan to help prevent the development of pressure Injuries?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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