A nurse is caring for a client who is it at risk for a pressure injury. Which of the following actions should the nurse take?
Keep the head of the client’s bed elevated to 45
Provide the client with a high-calorie diet.
Massage the client’s bony prominences.
Reposition the client every 4 hr.
The Correct Answer is B
A) Keep the head of the client’s bed elevated to 45 degrees:
Elevating the head of the bed to 45 degrees can actually increase the risk of pressure injuries, particularly in clients who are already at risk. This position can cause shearing forces and increase pressure on areas such as the sacrum, heels, and hips, making it more likely for pressure ulcers to develop.
B) Provide the client with a high-calorie diet:
A high-calorie diet is important for clients at risk of pressure injuries because adequate nutrition supports skin integrity and wound healing. Clients at risk for pressure injuries often have compromised nutritional status, and providing sufficient calories, protein, and other nutrients helps improve tissue regeneration and resilience. A high-calorie, high-protein diet helps prevent further breakdown of the skin and supports the healing process for any existing wounds.
C) Massage the client’s bony prominences:
Massaging bony prominences, such as the heels, elbows, and sacrum, is not recommended because it can cause tissue damage and increase the risk of pressure injury. Instead, the focus should be on minimizing pressure on these areas and using appropriate methods to redistribute pressure, such as repositioning the client or using pressure-relieving devices.
D) Reposition the client every 4 hours:
Repositioning the client every 4 hours may not be frequent enough for those at high risk for pressure injuries. For individuals who are immobile or at high risk, repositioning should typically occur at least every 2 hours to alleviate pressure on vulnerable areas of the body.
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Related Questions
Correct Answer is D
Explanation
A) Experiencing the pain of grief:
Experiencing the pain of grief is one of the early stages of mourning, according to Worden's tasks of grieving. This task involves confronting and processing the emotional pain and sorrow that accompany the loss. However, the statement provided by the client — "I am learning how to pay my own bills" — suggests they are adapting to life changes and responsibilities, which is more aligned with the later stages of grieving. This does not reflect the immediate pain of grief, but rather a focus on adjusting to life after the loss.
B) Finding an enduring connection while embarking on a new life:
Finding an enduring connection while embarking on a new life refers to the task of establishing a continued relationship with the deceased, while simultaneously moving forward with one's life. While this task is essential in the long-term grieving process, it does not directly relate to the client's statement, which focuses on practical changes, such as learning to manage finances, rather than a spiritual or emotional connection with the deceased.
C) Accepting the reality of the loss:
Accepting the reality of the loss is another important task in Worden’s model. This involves coming to terms with the fact that the loved one is gone. However, the client's focus on learning practical tasks like paying bills indicates that they are already moving beyond the initial stages of grief, not just accepting the loss. The statement does not clearly indicate that the client is still in the phase of accepting the reality of the loss, but rather adjusting to the changes that the loss has brought.
D) Adjusting to an environment without the deceased:
The client's statement, "I am learning how to pay my own bills," suggests they are taking on new responsibilities and adjusting to the changes brought about by the death of their partner. This aligns with Worden’s task of adjusting to an environment without the deceased, which includes taking on new roles and responsibilities that the deceased partner previously managed, such as financial tasks, household duties, and other life changes.
Correct Answer is C
Explanation
A) They bend at the ho when lifting:
This statement seems to be a typographical error, but it likely refers to "bending at the hips" when lifting. While bending at the hips can help reduce strain on the back, it is not the ideal body mechanic for lifting heavy objects. Proper lifting techniques involve bending at the knees, not the hips, to maintain proper alignment and reduce the risk of injury to the lower back. The correct form would be to squat down using the legs and keeping the back straight.
B) They keep their feet together when lifting an object:
Keeping the feet together when lifting an object is not advisable. The nurse should keep their feet shoulder-width apart for stability when lifting heavy objects. This wide stance provides a stable base and helps prevent loss of balance or strain during the lift. Keeping feet together would increase the risk of losing balance and possibly causing injury.
C) They stand close to the object being moved:
Standing close to the object being moved is the correct body mechanic. When lifting, the nurse should position themselves close to the object to minimize the leverage needed to lift it. By maintaining a short distance from the object, the nurse can use their legs to lift rather than relying on their back, which helps reduce the risk of back strain or injury.
D) They twist their spine when lifting:
Twisting the spine when lifting is a dangerous action that increases the risk of back injury. Proper body mechanics require that the nurse keep the back straight and avoid twisting the spine during the lift. Instead, they should rotate their whole body, moving their feet to turn, rather than twisting the spine. Twisting puts unnecessary stress on the spinal discs and can lead to muscle strain or injury.
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