The RN identifies that a client is at risk for impaired skin integrity.
Which interventions should the nurse add to this client’s plan of care?

Place the patient in a side-lying position only.

Massage bony prominences.

Use positioning devices such as foam wedges.

Keep the head of the bed elevated higher than 30 degrees. E. Inspect skin every shift.

Answer and Explanation

The Correct Answer is C

his intervention can help prevent pressure ulcers by reducing the amount of pressure on bony prominences and promoting blood circulation to the skin.

Choice A is wrong because placing the patient in a side-lying position only can increase the risk of skin breakdown by limiting the patient’s mobility and exposing the same areas to pressure. The patient should be repositioned frequently and encouraged to change positions if able.

Choice B is wrong because massaging bony prominences can cause tissue damage and increase the risk of skin breakdown by impairing blood flow to the area. Massaging should be avoided over bony prominences and areas of redness.

Choice D is wrong because keeping the head of the bed elevated higher than 30 degrees can cause shearing forces on the skin, which can lead to skin breakdown. The head of the bed should be kept at the lowest degree of elevation possible.

Choice E is wrong because inspecting skin every shift is not enough for a patient at risk for impaired skin integrity. The skin should be inspected at least every 2 hours or more frequently depending on the patient’s condition. Early detection of skin changes can help prevent further damage and promote healing.

Normal ranges for skin integrity are:

• Skin color: consistent with ethnicity and genetic background, no pallor, cyanosis, or jaundice.

• Skin moisture: dry to touch, no excessive perspiration or dryness. • Skin texture: smooth, soft, intact, with even surface.

• Skin temperature: warm to touch, no hyperthermia or hypothermia. • Skin turgor: elastic, returns to original shape after being pinched. • Skin integrity: no lesions, wounds, abrasions, or ulcers.

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Correct Answer is D

Explanation

Malignant hyperthermia is a severe reaction to certain drugs used for anesthesia that can cause muscle rigidity, fever, and a fast heart rate. It can be fatal if not treated promptly with medication, oxygen, body cooling, and supportive care. The patient’s symptoms match those of malignant hyperthermia.

Choice A is wrong because alpha-1 antitrypsin deficiency is a genetic disorder that affects the lungs and liver, causing shortness of breath, wheezing, and jaundice.

It does not cause a rise in body temperature or muscle rigidity. Choice B is wrong because malignant hypothermia does not exist. It is a misspelling of malignant hyperthermia.

Choice C is wrong because thalassemia is a genetic disorder that affects the production of hemoglobin, causing anemia, fatigue, and bone deformities.

It does not cause a rise in body temperature or muscle rigidity.

A. Maintain a regular sleep routine. B. Eat 3 large meals a day. C. Limit refined sugar, fried foods, and processed foods. D. Take daily walks. E. Take more coffee.

Correct Answer is ["A","C","D"]

Explanation

Choice A is correct because maintaining a regular sleep routine can help regulate your circadian rhythm, which is your body’s natural sleep-wake cycle. This can improve the quality and quantity of your sleep and reduce daytime sleepiness.

Choice B is wrong because eating three large meals a day can cause fluctuations in your blood sugar levels, which can affect your energy levels. It is better to eat smaller, more frequent meals and snacks that contain a balance of protein and carbohydrates to keep your blood sugar stable and provide sustained energy. Choice C is correct because limiting refined sugar, fried foods and processed foods can help prevent fatigue by reducing inflammation and oxidative stress in your body.

These foods can also cause spikes and crashes in your blood sugar levels, which can make you feel tired and hungry. Instead, you should eat more anti-inflammatory foods, such as fruits, vegetables, nuts, seeds and fish.

Choice D is correct because taking daily walks can help prevent fatigue by increasing your blood circulation, oxygen delivery and endorphin production. Exercise can also improve your mood, sleep quality and immune system.

Choice E is wrong because increasing caffeine intake can have the opposite effect of preventing fatigue.

Caffeine is a stimulant that can temporarily boost your energy levels, but it can also disrupt your sleep, cause dehydration, increase anxiety and lead to withdrawal symptoms

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The RN identifies that a client is at risk for impaired skin integrity. Which interventions should the nurse add to this client’s plan of care?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is caring for a patient who has complaints of fatigue. If the fatigue is caused by lifestyle choices, what should the nurse recommend for fatigue prevention? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

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The RN identifies that a client is at risk for impaired skin integrity.
Which interventions should the nurse add to this client’s plan of care?