An older adult client with a stage one sacral pressure wound is discharged with instructions for home care. Which information should the practical nurse reinforce with the client?

Apply lotion to sacrum.

Use wet-to-dry dressings daily.

Elevate head of bed 30 degrees.

Change positions every 2 hours.

Answer and Explanation

The Correct Answer is D

A. Apply lotion to sacrum: Applying lotion may help with general skin hydration but does not directly address pressure relief, which is the primary intervention needed to prevent worsening of a stage one pressure injury.
B. Use wet-to-dry dressings daily: Wet-to-dry dressings are used for wounds with necrotic tissue that need debridement. A stage one pressure injury involves intact skin without an open wound, so such dressings are not appropriate.
C. Elevate head of bed 30 degrees: Elevating the head of the bed slightly can reduce aspiration risk but also increases pressure on the sacrum if maintained for long periods. Position changes are more critical to relieve sacral pressure.
D. Change positions every 2 hours: Repositioning every two hours is essential to relieve pressure on the sacrum and promote circulation. This practice helps prevent progression of the pressure injury and is a cornerstone of effective pressure ulcer prevention.

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Correct Answer is ["A","B","C","D","E"]

Explanation

A. Effects of sleep loss: Assessing how sleep loss affects daytime functioning helps determine the severity of the insomnia and guides appropriate interventions for improving sleep quality.
B. Bedtime rituals: Understanding the client’s bedtime habits can reveal behaviors that may either promote or interfere with sleep, allowing for targeted recommendations to enhance sleep hygiene.
C. Alcohol consumption: Alcohol can disrupt sleep cycles and contribute to insomnia, even if it initially seems to induce sleep. Evaluating alcohol use helps identify modifiable factors affecting sleep quality.
D. Sleep expectations: Unrealistic sleep expectations, such as expecting to fall asleep immediately or sleep for excessive hours, can contribute to anxiety around sleep. Clarifying expectations can help adjust behaviors and improve outcomes.
E. Current life events: Stressful life events are a common cause of insomnia. Exploring recent stressors provides important context for developing an effective and individualized care plan to address sleep disturbances.

A. Acknowledge the client's concerns and notify the healthcare provider of the client's wishes. B. Ask a family member to describe the client's stated wishes regarding end-of-life care. C. Explain that the form identifies his personal health care wishes for any future event. D. Document his refusal in his electronic medical record using his exact words.

Correct Answer is C

Explanation

A. Acknowledge the client's concerns and notify the healthcare provider of the client's wishes: While it is important to acknowledge the client's feelings, immediately notifying the healthcare provider is not the first or most critical action. The client first needs a clear explanation of the purpose of the advance directive.
B. Ask a family member to describe the client's stated wishes regarding end-of-life care: Involving family members at this stage may undermine the client's autonomy. The focus should be on informing and empowering the client to make his own decisions.
C. Explain that the form identifies his personal health care wishes for any future event: It is important to clarify that advance directives are not just for those who are dying but help ensure that healthcare decisions align with the client’s wishes if he becomes unable to communicate in the future. Clear communication can ease misunderstandings and support informed decision-making.
D. Document his refusal in his electronic medical record using his exact words: While documentation is important, it should occur after ensuring that the client fully understands the purpose of the form. Providing education first supports client rights and informed consent.

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An older adult client with a stage one sacral pressure wound is discharged with instructions for home care. Which information should the practical nurse reinforce with the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","C","D","E"]

Explanation

Correct Answer is C

Explanation

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