A nurse is performing a skin assessment for a client who has been on bed rest for 1 week. The nurse notes reddened areas on the client's scapulae. Which of the following actions should the nurse take?

Provide the client with high-protein meals.

Gently massage the reddened areas.

Place the client in a supine position.

Use hot water when cleaning the client's skin.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Provide the client with high-protein meals: High-protein meals are important for tissue repair and healing, especially in clients at risk for pressure ulcers. Adequate nutrition, including protein, is essential to promote skin integrity and prevent further skin breakdown.

B. Gently massage the reddened areas: Massaging reddened areas can increase tissue damage and worsen skin breakdown. Instead of massaging, the nurse should relieve pressure on those areas to prevent further injury.

C. Place the client in a supine position: The supine position might increase pressure on the client's scapulae. It is better to reposition the client to relieve pressure from affected areas, ideally by turning them to their side or using pillows to offload pressure.

D. Use hot water when cleaning the client's skin: Hot water can dry and irritate the skin, worsening the condition. The nurse should use lukewarm water and gentle, non-irritating products to clean the skin and prevent further damage.

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Correct Answer is B

Explanation

Rationale:

A. "Discontinue opioids before trying nonpharmacological methods of pain relief."
Nonpharmacological methods should complement, not replace, opioids. It's important to continue prescribed medications and incorporate nonpharmacological techniques to manage chronic pain.

B. "Distraction changes the client's perception of pain, but it does not affect the cause."
Distraction techniques, like listening to music, can alter pain perception by redirecting attention, but they do not address the underlying cause of pain.

C. "Use imagery with clients who have difficulty with focus and concentration." Imagery is a relaxation technique that requires focus. It may not be effective for clients with concentration difficulties, as they may struggle to benefit from this method.

D. "Pain relief from the use of heat and cold continues for several hours after removal of the stimulus." Pain relief from heat and cold is temporary and typically fades once the stimulus is removed. It provides short-term relief and should not be expected to last long after application.

A. "Drink a glass of milk with each meal." B. "Plan to include high-protein foods in each of your meals." C. "Increase your intake of vegetables such as broccoli and brussels sprouts." D. "Consume three large meals throughout the day."

Correct Answer is B

Explanation

Rationale:

A. "Drink a glass of milk with each meal." While milk can be a good source of calcium and protein, it may increase mucus production, which can be uncomfortable for clients with COPD or increase the work of breathing.

B. "Plan to include high-protein foods in each of your meals. "High-protein foods are essential for clients with COPD, as they help maintain muscle mass, support immune function, and prevent weight loss. These benefits are important for COPD patients, who may experience increased energy expenditure due to labored breathing.

C. "Increase your intake of vegetables such as broccoli and brussels sprouts." While vegetables are important, certain cruciferous vegetables like broccoli and brussels sprouts can cause gas and bloating, which can lead to discomfort for clients with COPD.

D. "Consume three large meals throughout the day." Clients with COPD may have difficulty consuming large meals due to breathlessness or early satiety. It is better to recommend smaller, more frequent meals to ensure adequate caloric intake.

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A nurse is performing a skin assessment for a client who has been on bed rest for 1 week. The nurse notes reddened areas on the client's scapulae. Which of the following actions should the nurse take?

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