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A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

Massage over erythematous bony prominences.

Minimize skin exposure to moisture.

Use pillows to keep heels off the bed surface.

Implement a turning schedule every 4 hours.

Keep the client's skin dry with powder.

Answer and Explanation

Correct Answer : B,C

The correct answer is b. Minimize skin exposure to moisture and c. Use pillows to keep heels off the bed surface.

Choice A reason:

a. Massage over erythematous bony prominences: This is incorrect because massaging erythematous (reddened) areas can cause further tissue damage and exacerbate skin breakdown.

Choice B reason:

b. Minimize skin exposure to moisture: This is correct. Moisture can lead to skin maceration, increasing the risk of skin breakdown. Keeping the skin dry helps maintain its integrity.

Choice C reason:

c. Use pillows to keep heels off the bed surface: This is correct. Elevating the heels reduces pressure on them, preventing pressure ulcers.

Choice D reason:

d. Implement a turning schedule every 4 hours: This is incorrect. To prevent pressure injuries, turning should be done every 2 hours, not every 4 hours.

Choice E reason:

e. Keep the client’s skin dry with powder: This is incorrect. Powder can cause skin irritation and breakdown.

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Correct Answer is A

Explanation

Choice A reason:
Difficulty with abduction of the arm at the shoulder is a common finding in clients with a rotator cuff injury. The rotator cuff is a group of muscles and tendons that stabilize the shoulder joint and facilitate its movement. When these muscles or tendons are injured, movements such as lifting the arm away from the body (abduction) can become painful and difficult.

Choice B reason:
Alteration in the contour of the joint is not typically associated with a rotator cuff injury. This finding is more indicative of conditions that cause changes in the bone structure, such as arthritis or dislocation.

Choice C reason:
A positive Tinel's sign is used to diagnose nerve compression or nerve damage, particularly in conditions like carpal tunnel syndrome. It is not a test used to assess rotator cuff injuries.

Choice D reason:
A negative drop arm test would suggest that the client does not have a rotator cuff injury. The drop arm test is performed by having the client lift the arm to 90 degrees and then slowly lower it. If the client can control the motion and lower the arm smoothly, the test is negative. A positive drop arm test, where the client cannot control the descent of the arm, would indicate a rotator cuff injury.

A. A client who has a temperature of 37.2°C (99°F) and a heart rate of 88/min. B. A client who has a heart rate of 132/min and a respiratory rate of 30/min. C. A client who has a decrease in level of consciousness and a heart rate greater than 130/min. D. A client who has bradypnea and a white blood cell (WBC) count of 10,000/mm³ (normal range: 5,000 to 10,000/mm³). E. A client who has a temperature of 36°C (96.8°F) and a respiratory rate of 16/min.

Correct Answer is ["B","C"]

Explanation

Choice A reason:
A temperature of 37.2°C (99°F) is slightly elevated but not necessarily indicative of sepsis. A heart rate of 88/min is within normal limits (60-100/min). This client's signs do not strongly suggest sepsis.

Choice B reason:
A heart rate of 132/min and a respiratory rate of 30/min are both elevated, which can be signs of sepsis. Sepsis can cause an increase in heart rate (tachycardia) and respiratory rate (tachypnea) as the body attempts to maintain adequate blood flow and oxygenation during a systemic infection.

Choice C reason:
A decrease in the level of consciousness combined with a heart rate greater than 130/min could indicate sepsis, as confusion or changes in mental status are common symptoms when the body is fighting a severe infection.

Choice D reason:
Bradypnea, or abnormally slow breathing, is not typically associated with sepsis, which more commonly causes rapid breathing. A WBC count of 10,000/mm³ is at the upper limit of the normal range and does not necessarily indicate sepsis without other symptoms.

Choice E reason:
A temperature of 36°C (96.8°F) is on the lower end of the normal body temperature range and does not suggest fever, which is a common sign of sepsis. A respiratory rate of 16/min is within the normal range (12-20/min) and does not indicate sepsis.

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A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

Choice A reason:

Choice B reason:

Choice C reason:

Choice D reason:

Choice E reason:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a rotator cuff injury. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a group of critically ill clients. Which of the following clients are exhibiting potential manifestations of sepsis? (Select all that apply)

Correct Answer is ["B","C"]

Explanation

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