A nurse is caring for a client who is immobile and developing skin breakdown. Which of the following actions should the nurse take?
Bathe the client with soap and hot water.
Massage bony prominences four times daily.
Keep the head of the client's bed at 30° or less.
Slide the client up in bed every 2 hr.
The Correct Answer is C
A. Bathe the client with soap and hot water: Hot water and soap can dry out the skin and worsen skin breakdown. The nurse should use lukewarm water and mild soap to prevent skin irritation, ensuring proper hydration and skin care.
B. Massage bony prominences four times daily: Massaging bony prominences can increase the risk of skin breakdown, as it may cause further tissue damage. Instead, the nurse should avoid massaging these areas and focus on preventive measures, such as repositioning.
C. Keep the head of the client's bed at 30° or less: Keeping the head of the bed at a 30° angle or less reduces pressure on the sacrum and other bony prominences. This position helps prevent further skin breakdown and promotes comfort for immobile clients.
D. Slide the client up in bed every 2 hr: Sliding the client up in bed increases friction, which can exacerbate skin breakdown. The nurse should use proper lifting techniques or assistive devices to reposition the client while minimizing friction and shearing forces.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I'm sure your family will be here soon.": While this response tries to reassure the client, it does not address the client’s current feelings or provide immediate support. It might also come across as dismissive since the nurse cannot be sure when the family will arrive.
B. "I will be available for you until your family arrives.": This response acknowledges the client’s anxiety and offers support in the meantime. It shows the nurse’s availability and commitment to making the client feel safe and supported while waiting for their family.
C. "Why do you think your family is delayed?": This question might make the client feel pressured or defensive and focuses on the delay rather than offering reassurance or emotional support. It does not directly address the client’s emotional needs.
D. "You'll feel better once this procedure is over.": While this response aims to reassure the client, it might minimize their current feelings of anxiety. It focuses on the future rather than addressing the immediate emotional needs of the client.
Correct Answer is B
Explanation
A. Cyclobenzaprine: Cyclobenzaprine is a muscle relaxant used to treat muscle spasms, not neuropathic pain. It is not the appropriate medication for managing pain associated with peripheral neuropathy.
B. Gabapentin: Gabapentin is commonly prescribed for neuropathic pain, such as that associated with peripheral neuropathy. It works by affecting the way nerves transmit pain signals, making it an effective treatment for chronic nerve pain.
C. Naproxen: Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) used for pain relief, but it is typically not effective for neuropathic pain. It is more commonly used for conditions involving inflammation, such as arthritis.
D. Oxycodone: Oxycodone is an opioid pain medication that is generally reserved for severe pain. While it may be prescribed for acute pain, it is not the first-line treatment for chronic neuropathic pain due to its potential for dependence and side effects.
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