Which activity should the nurse implement to decrease shearing force on a client's stage Il pressure injury?

pulling the client up from under the arms

improving the client's hydration

lubricating the area with skin cream

preventing the client from sliding in bed

Answer and Explanation

The Correct Answer is D

A) Pulling the client up from under the arms: This action can increase shearing force on the client's skin, especially if done abruptly or without proper assistance. Pulling the client up by the arms can create friction and shear between the skin and underlying tissues, potentially worsening the pressure injury.
B) Improving the client's hydration: While hydration is essential for overall skin health, it is not directly related to reducing shearing force on a pressure injury. Hydration can help maintain skin integrity and promote healing but does not directly address the mechanical forces contributing to pressure injuries.
C) Lubricating the area with skin cream: While skin cream can help moisturize and protect the skin, it may not necessarily reduce shearing force on a pressure injury. While lubrication can reduce friction between surfaces, it may not be sufficient to prevent shearing forces that occur during movement or repositioning.
D) Preventing the client from sliding in bed: This is the most appropriate action to decrease shearing force on a stage II pressure injury. Sliding in bed can exacerbate shearing forces on the skin, leading to further damage or delayed healing of the pressure injury. Using devices such as pillows, positioning aids, or specialized mattresses can help prevent the client from sliding and minimize shearing forces on the affected area, promoting healing and preventing further injury.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "It sounds like you are exhausted."
This response demonstrates empathy and acknowledges the client's emotional state. The "E" in the NURSE mnemonic stands for "empathize," which involves recognizing and validating the client's feelings. By acknowledging that the client may be exhausted, the nurse shows understanding and empathy towards the client's experience of feeling overwhelmed.

B. "Tell me more about how you are feeling."
This response demonstrates active listening and encourages the client to express their emotions further. While important for therapeutic communication, it does not specifically address the client's feeling of being overwhelmed as directly as option A.

C. "You have so much to deal with. How can I be of help to you?"
This response demonstrates support and willingness to assist the client but does not directly address the client's reported feeling of being overwhelmed.

D. "It is impressive how you have managed to deal with the situation."
This response offers praise but does not directly address the client's reported feeling of being overwhelmed. It may also inadvertently minimize the client's feelings by focusing on their ability to cope rather than acknowledging their current emotional state.

A. Continue to talk to the client as if they are awake. B. Limit the client's visitors to one at a time. C. Avoid touching the client D. Whisper when talking in the client's room

Correct Answer is A

Explanation

A. Continue to talk to the client as if they are awake: Even though the client is unresponsive, hearing can be the last sense to diminish as death approaches. Speaking to the client in a calm and reassuring manner can provide comfort and a sense of presence, even if the client cannot respond verbally.

B. Limit the client's visitors to one at a time: While it's important to manage visitors to prevent overwhelming the client, limiting them to one at a time may not be necessary if the client's condition allows for multiple visitors and the client's wishes or cultural preferences support it.

C. Avoid touching the client: Touch can be a powerful form of communication and comfort, even for an unresponsive client. Gentle touch can convey warmth and support to both the client and their family members.

D. Whisper when talking in the client's room: Whispering may create a sense of unease or anxiety for the client or their family members. Speaking in a calm and soothing voice at a normal volume is more appropriate and can help create a peaceful environment for the client's end-of-life care.

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Which activity should the nurse implement to decrease shearing force on a client's stage Il pressure injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using the NURSE mnemonic when speaking with a client who is experiencing grief. The client reports that they are feeling overwhelmed. Which of the following responses by the nurse demonstrates the "E” in the NURSE mnemonic?

Correct Answer is A

Explanation

A nurse is caring for a client who is at the end of life and is unresponsive. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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