A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?

Reposition the client every 3 hours.

Apply cornstarch to keep the skin dry.

Provide the client with a diet high in protein.

Massage bony prominences to promote circulation.

Answer and Explanation

The Correct Answer is C

A diet high in protein can help maintain skin integrity in older adults. Protein is essential for tissue repair and wound healing. The other options may not be as effective in maintaining skin integrity. For example, repositioning the client every 3 hours may not be frequent enough to prevent pressure ulcers. Applying cornstarch to keep the skin dry may not be the best option as it is important to keep the skin moisturized. Massaging bony prominences to promote circulation may not be recommended as it could cause damage to fragile skin.

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Correct Answer is D

Explanation

The nurse should immediately report a respiratory rate of 8 to the physician. A normal respiratory rate for an adult is between 12 and 20 breaths per minute. A respiratory rate of 8 is considered abnormally low and can indicate respiratory depression, which can be a side eﬀect of pain medication delivered through an epidural catheter. It is important for the nurse to report this finding immediately so that appropriate interventions can be taken to ensure the safety of the client.

A. Bargaining B. Denial C. Anger D. Depression

Correct Answer is B

Explanation

According to Kubler-Ross's stages of grieving, denial is the first stage. It is a defense mechanism that helps individuals cope with the overwhelming emotions associated with loss. In this case, the client is refusing to believe that the loss of her husband is happening and is likely experiencing denial as a way to cope with her grief

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A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?

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