A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan?
Massage the client's red bony prominences.
Assess the client's skin for increased coolness.
Reposition the client every 2 hr.
Keep the client's skin moist.
The Correct Answer is C
A. Massaging red bony prominences may cause further skin damage and increase the risk of pressure ulcers.
B. Skin should be assessed for warmth, redness, and integrity, but coolness is not necessarily an indicator of pressure injury.
C. Repositioning every 2 hours is essential for preventing pressure ulcers in bed-bound clients by relieving pressure on vulnerable areas.
D. Keeping the skin moist increases the risk of skin breakdown. It is important to keep the skin dry and clean.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Major depressive disorder can affect bowel habits, but it is more commonly associated with constipation rather than diarrhea.
B. Stress, such as that experienced by the 21-year-old female with multiple final exams, can lead to gastrointestinal symptoms like diarrhea due to the effect of stress hormones on the digestive system.
C. Ignoring the urge to defecate typically leads to constipation rather than diarrhea.
D. Older adults are at risk for constipation due to reduced intestinal motility rather than diarrhea, unless they are taking medications that can cause diarrhea.
Correct Answer is B
Explanation
A. Ripe bananas can help alleviate diarrhea due to their fiber content and are often recommended to regulate bowel movements.
B. Caffeinated beverages, such as coffee and tea, are known to increase intestinal motility and can lead to diarrhea.
C. White rice is a low-fiber, easily digestible food that typically helps manage diarrhea.
D. Low-fiber cereals are not likely to cause diarrhea, as fiber tends to bulk stool rather than loosen it.
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