A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

Massage the client’s bony prominences.

Keep the head of the bed elevated.

Reposition the client at least every 2 hr.

Keep the client’s skin moist.

Answer and Explanation

The Correct Answer is C

A. Massage the client’s bony prominences:

Massaging bony prominences is generally not recommended for individuals at risk for pressure ulcers. Massage can increase friction and shear forces on the skin, which may contribute to skin damage rather than prevent it. Gentle, careful handling of the skin is preferable.

B. Keep the head of the bed elevated:

While elevating the head of the bed may be appropriate for certain medical conditions, it is not a primary preventive measure for pressure ulcers. In fact, keeping the head of the bed elevated continuously can contribute to pressure on the sacrum and coccyx, increasing the risk of pressure ulcers in those areas.

C. Reposition the client at least every 2 hr:

Regular repositioning is a crucial preventive measure for pressure ulcers. Repositioning helps redistribute pressure, improves blood flow to vulnerable areas, and reduces the risk of skin breakdown.

D. Keep the client’s skin moist:

While maintaining skin moisture is important to prevent dryness and cracking, excessive moisture can contribute to skin breakdown. The emphasis should be on keeping the skin clean and dry, with the use of moisturizers applied judiciously to prevent excessive dryness.

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Correct Answer is A

Explanation

A. “Increase your caloric intake by eating foods high in protein.”

This is the appropriate choice. Increasing caloric intake with high-protein foods can help meet nutritional needs for individuals with Crohn's Disease, especially if malabsorption is a concern.

B. “Include fresh fruits and vegetables at each meal.”

While fresh fruits and vegetables are generally healthy, they may exacerbate symptoms in some individuals with Crohn's Disease, especially during flare-ups. It may be advisable to choose cooked or processed fruits and vegetables to minimize irritation.

C. “Maintain your weight by eating high-fat foods.”

This statement is not advisable. High-fat foods can contribute to symptoms such as cramping and diarrhea in individuals with Crohn's Disease. A well-balanced diet with an appropriate mix of nutrients is generally recommended.

D. “Drink whole milk to ensure adequate calcium intake.”

This statement is not advisable without considering individual tolerance. Whole milk is high in fat and may be difficult to digest for some individuals with Crohn's Disease. Additionally, if lactose intolerance is present, it may worsen symptoms. Alternative sources of calcium may need to be considered.

A. Remind the client to tell the nurse when he has to urinate B. Use adult diapers to prevent frequent clothing changes. C. Take the client to the bathroom on an every-2-hr schedule. D. Request a prescription for an indwelling urinary catheter.

Correct Answer is C

Explanation

A. Remind the client to tell the nurse when he has to urinate.
Reminding the client may not be effective, as individuals with dementia may have difficulty expressing their needs or may forget to communicate when they need to use the bathroom. It relies on the client's ability to remember and communicate.

B. Use adult diapers to prevent frequent clothing changes.
While adult diapers can be part of a comprehensive plan for managing incontinence, they should not be the sole intervention. Relying solely on diapers does not address the underlying causes of incontinence and may not promote optimal dignity and quality of life.

C. Take the client to the bathroom on an every-2-hr schedule.
This is the correct choice. Taking the client to the bathroom on a regular schedule (timed voiding) is a proactive approach to managing urinary incontinence in individuals with dementia. It helps reduce the likelihood of accidents by ensuring regular opportunities for toileting.

D. Request a prescription for an indwelling urinary catheter.
Indwelling urinary catheters are generally not recommended for managing routine urinary incontinence due to the associated risks, including infection. Catheters should be used judiciously and based on medical necessity.

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A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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