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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Answer: A, C, D, E
Rationale:
A) Yoga: Yoga is an effective nonpharmacological therapy that combines physical postures, breathing exercises, and meditation, which can help reduce stress, improve flexibility, and enhance mental focus.
B) Electromagnetic therapy: Electromagnetic therapy is typically used for pain management or to promote wound healing rather than stress reduction. It is not commonly included in stress management techniques.
C) Meditation: Meditation focuses on mindful breathing and awareness, which can significantly reduce stress by calming the mind and improving emotional resilience. It’s widely used to help manage stress and anxiety.
D) Acupuncture: Acupuncture involves the insertion of needles at specific body points and is believed to release endorphins and balance energy flow, which can reduce stress and promote relaxation.
E) Biofeedback: Biofeedback teaches clients to control physiological responses like heart rate and muscle tension, helping them manage stress and anxiety effectively through self-regulation techniques.
Correct Answer is D
Explanation
A) Administer and teach about medications to suppress stage III sleep:
Suppressing stage III sleep is not a primary intervention for sleepwalking and could potentially disrupt the client’s overall sleep quality.
B) Encourage the child to verbalize feelings regarding sleep pattern:
While understanding feelings about sleep patterns may be helpful, it is not the immediate priority in managing sleepwalking.
C) Provide a quiet environment for nighttime sleep:
A quiet environment is generally beneficial for good sleep hygiene but does not directly address the safety concerns associated with sleepwalking.
D) Maintain patient safety during episodes of somnambulism:
Ensuring the client’s safety is the primary focus. Sleepwalking can lead to accidents or injuries; therefore, implementing safety measures to prevent harm during episodes of somnambulism is crucial. This may include securing the environment, using safety gates, and ensuring the client’s immediate surroundings are safe.
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