A nurse is assessing a client who has a heart rate of 115. Which of the following is the medical term?

A reason:

A young adult in skeletal balanced suspension traction is at risk for skin breakdown due to immobility, but they are typically more resilient compared to older adults. Age and overall health are important factors in skin integrity.

B reason:

An older adult with a hip fracture and in Buck's traction is at greatest risk for skin breakdown. Older adults have thinner, more fragile skin, and are more prone to complications from immobility. Buck's traction also limits mobility, increasing the risk of pressure ulcers.

C reason:

An adolescent in a halo brace has a risk for skin breakdown, particularly around the pin sites and under the brace, but adolescents generally have better skin resilience and healing capacity compared to older adults.

D reason:

A middle adult with a fractured radius and an arm cast is at minimal risk for skin breakdown compared to the other scenarios. This situation typically allows for more mobility and less pressure on vulnerable skin areas.

A reason:

A gait belt is appropriate for assisting a client who sometimes loses balance. It provides a secure grip for the nurse to help stabilize and support the client during ambulation.

B reason:

A jacket harness is typically used for clients requiring more substantial support and restraint, not just for occasional balance issues. It is not as commonly used for simple ambulation assistance.

C reason:

A cane can help with balance, but in this scenario, the question is about the device the nurse should use, not what the client should use. The nurse should use a gait belt to provide immediate support.

D reason:

A four-wheel walker provides significant support but may not be necessary if the client's balance issues are occasional. The question focuses on what the nurse should use to assist, making the gait belt the most appropriate choice for providing support during ambulation.