A client is bedridden and appears to be frail and malnourished. Which nursing interventions will most effectively prevent skin injury? (Select all that apply.)
Cleansing the skin routinely after soiling occurs.
Applying moisturizer to dry areas of skin.
Using a Hoyer lift for all transfers.
Massaging the client’s reddened shoulders and heels.
Repositioning the client once per shift.
Correct Answer : A,B,C
Choice A reason: Cleansing the skin routinely after soiling occurs is an effective intervention to prevent skin injury. This is because soiling from urine, feces, sweat, or wound drainage can irritate the skin and cause inflammation, infection, or breakdown. The nurse should use a gentle cleanser and warm water and pat the skin dry. The nurse should also avoid using harsh chemicals, alcohol, or perfumes on the skin.
Choice B reason: Applying moisturizer to dry areas of skin is an effective intervention to prevent skin injury. This is because dry skin is more prone to cracking, peeling, or tearing. The nurse should use a hypoallergenic moisturizer and apply it to the skin after cleansing and drying. The nurse should also avoid using products that contain alcohol, fragrances, or dyes on the skin.
Choice C reason: Using a Hoyer lift for all transfers is an effective intervention to prevent skin injury. This is because a Hoyer lift is a mechanical device that helps to lift and move the client safely and comfortably. It reduces the friction and shear on the skin by lifting the client off the bed surface and avoiding any sliding or dragging. It also prevents the nurse from injuring themselves by lifting the client manually.
Choice D reason: Massaging the client’s reddened shoulders and heels is not an effective intervention to prevent skin injury. In fact, this may worsen the skin injury by increasing the pressure and damage to the tissues. The nurse should avoid massaging any areas that are reddened, swollen, or blistered, as these are signs of pressure ulcers. The nurse should instead relieve the pressure by repositioning the client or using pressurerelieving devices, such as pillows, foam pads, or air mattresses.
Choice E reason: Repositioning the client once per shift is not an effective intervention to prevent skin injury. This is because repositioning the client once per shift is not frequent enough to prevent the development of pressure ulcers. Pressure ulcers are caused by prolonged pressure on the skin that reduces the blood flow and oxygen to the tissues. The nurse should reposition the client at least every 2 hours or more often if needed, depending on the client's condition and risk factors.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: "Tell me about what medications you are taking." is not the most appropriate statement by the nurse, because it is not related to the psychosocial assessment. Medications are part of the physical or pharmacological assessment, which focuses on the type, dose, frequency, and effectiveness of the drugs that the client is taking for rheumatoid arthritis. Medications may have some psychosocial implications, such as side effects, costs, or adherence, but they are not the main focus of the psychosocial assessment.
Choice B reason: "What physical limitations are you experiencing?" is not the most appropriate statement by the nurse, because it is not related to the psychosocial assessment. Physical limitations are part of the functional or mobility assessment, which focuses on the range of motion, strength, endurance, and coordination of the joints and muscles that are affected by rheumatoid arthritis. Physical limitations may have some psychosocial implications, such as pain, disability, or dependence, but they are not the main focus of the psychosocial assessment.
Choice C reason: "How does this impact your role in your family?" is the most appropriate statement by the nurse, because it is related to the psychosocial assessment. Role in the family is part of the social or relational assessment, which focuses on the interactions, responsibilities, and expectations of the client and their family members in relation to rheumatoid arthritis. Role in the family may have significant psychosocial implications, such as role changes, role conflicts, role strain, or role loss, which can affect the client's selfesteem, identity, and coping.
Choice D reason: "What therapies are you using to reduce swelling?" is not the most appropriate statement by the nurse, because it is not related to the psychosocial assessment. Therapies are part of the physical or nonpharmacological assessment, which focuses on the modalities, techniques, or devices that the client is using to manage the symptoms of rheumatoid arthritis. Therapies may have some psychosocial implications, such as availability, accessibility, or preference, but they are not the main focus of the psychosocial assessment.
Correct Answer is B
Explanation
Choice A reason: The main side effect of acetaminophen is gastrointestinal (GI) bleeding is not a teaching that the nurse should include in the education, because it is incorrect and misleading. Acetaminophen is a pain reliever and fever reducer that is commonly used for osteoarthritis, but it does not have antiinflammatory properties. Acetaminophen does not cause GI bleeding, unlike NSAIDs, which can irritate the stomach lining and increase the risk of ulcers and bleeding. The main side effect of acetaminophen is liver damage, which can occur if the dose is exceeded or if the drug is combined with alcohol or other hepatotoxic substances.
Choice B reason: You should not take more than 4000 mg of acetaminophen a day is a teaching that the nurse should include in the education, because it is correct and important. Acetaminophen has a maximum daily dose of 4000 mg for adults, which should not be exceeded to avoid the risk of liver damage or overdose. Acetaminophen can be found in many overthecounter and prescription products, such as cold and flu remedies, cough syrups, or combination analgesics. Therefore, the client should read the labels carefully and keep track of the total amount of acetaminophen they are taking from all sources.
Choice C reason: Nonsteroidal antiinflammatory drugs (NSAIDs) are very safe and have no side effects is not a teaching that the nurse should include in the education, because it is incorrect and misleading. NSAIDs are a group of drugs that have antiinflammatory, analgesic, and antipyretic effects, and that are commonly used for osteoarthritis. However, NSAIDs are not very safe and have many side effects, such as GI bleeding, ulcers, kidney damage, cardiovascular events, allergic reactions, or interactions with other drugs. Therefore, the client should use NSAIDs with caution and under the supervision of the provider.
Choice D reason: The most common adverse effect of nonsteroidal antiinflammatory drugs (NSAIDs) are liver failure and tinnitus is not a teaching that the nurse should include in the education, because it is incorrect and misleading. Liver failure and tinnitus are not the most common adverse effects of NSAIDs, but rather rare and serious ones. Liver failure can occur in some cases of NSAID overdose or hypersensitivity, while tinnitus can occur in some cases of NSAID toxicity or high doses. The most common adverse effects of NSAIDs are GI bleeding, ulcers, or irritation, which can affect up to 15% of the users.
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