A young adult client is brought to the emergency department reporting a headache. The client has bruises around the face and on the upper arms. The nurse suspects the client is the victim of physical abuse. In which order should the nurse implement these interventions? (Arrange the nursing actions with the highest priority first, on top, and lowest priority last, on bottom.)

A. Apply a zinc-based cream with brief changes. Zinc-based creams create a protective barrier against moisture and irritation from incontinence. This helps prevent skin breakdown by reducing the effects of prolonged exposure to urine and stool.
B. Apply powder to the perineum. Powder can cause clumping when mixed with moisture, increasing friction and leading to skin irritation. It is not the preferred method for preventing skin breakdown in incontinent patients.
C. Provide a donut-shaped pillow to sit on. Donut-shaped pillows create pressure points around the edges, which can worsen pressure injuries rather than prevent them. A pressure-relieving cushion is a better alternative.
D. Use an antimicrobial soap to clean skin. Harsh soaps can strip the skin of its natural protective oils, leading to dryness and irritation. A mild, pH-balanced cleanser is recommended for skin care.
E. Place a foam pad on the bed. Foam pads help redistribute pressure and reduce friction, lowering the risk of pressure injuries for patients who have limited mobility and spend extended time in bed.
F. Ensure the client slides up in bed on their own. Allowing the client to slide in bed increases friction and shearing forces, leading to skin breakdown. Assisted repositioning is necessary to prevent injury.
G. Two-person assist to move up in bed using a slide sheet. Using a slide sheet with assistance minimizes friction and shear, which are significant contributors to pressure ulcers. This method helps protect fragile skin.
H. Elevate the head of the bed above 30 degrees. Elevating the bed above 30 degrees increases pressure on the sacrum and coccyx, heightening the risk of skin breakdown. A lower elevation is preferred unless contraindicated.
I. Request a physical therapy consult. A physical therapy consult can help improve mobility, strength, and positioning techniques, reducing prolonged pressure on vulnerable areas and promoting skin integrity.

A. Anaphylactic. Anaphylactic reactions are caused by severe allergic responses, leading to histamine release, vasodilation, and bronchoconstriction. While burns trigger an immune response, it is an inflammatory reaction rather than an allergic one.
B. Noncompensatory. The body's response to burns is compensatory, not noncompensatory. The body immediately reacts by activating the inflammatory and stress responses to maintain perfusion and initiate healing.
C. Inflammatory. A severe burn triggers an immediate and massive inflammatory response, causing capillary leakage, fluid shifts (burn shock), and immune activation. This leads to edema, hypovolemia, and increased risk of infection. The inflammatory response also activates cytokines and white blood cells to begin tissue repair.
D. Cholinergic. The cholinergic response is related to the parasympathetic nervous system, which controls rest-and-digest functions. Severe burns primarily activate the sympathetic nervous system (fight-or-flight), leading to vasoconstriction, tachycardia, and increased metabolic demands.