Because thin skin and lack of subcutaneous fat predisposes the older adult to pressure injuries, the nurse alters the care plan to include turning the bedfast patient how often?
Each evening
Once every shift
Every 4 hours
Every 2 hours
The Correct Answer is D
A. Each evening: Turning the patient only once per day is insufficient to prevent pressure injuries.
B. Once every shift: This is also inadequate as it does not provide the frequent repositioning necessary to prevent pressure injuries.
C. Every 4 hours: While better than every shift, every 4 hours may still not be frequent enough to prevent pressure injuries in at-risk patients.
D. Every 2 hours: Frequent repositioning, such as every 2 hours, is essential for pressure injury prevention in bedfast patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bipolar disorder: The described behavior of extreme mood swings (elevated mood followed by significant depression) is characteristic of bipolar disorder.
B. Dysthymic disorder: Dysthymic disorder (now known as persistent depressive disorder) involves a chronic state of depression but does not typically feature such pronounced mood swings.
C. Hypomanic episode: A hypomanic episode would involve elevated mood but would not usually be followed by the severe depressive episode described.
D. Unipolar depression: Unipolar depression is characterized by a persistent low mood rather than the dramatic shifts described.
Correct Answer is B
Explanation
A. "What we say can be secret. What I write in the chart is available to the health team." This response lacks clarity about legal and ethical obligations.
B. "I am required to report any intent to hurt yourself or others." This response clearly communicates the legal and ethical obligation to protect the patient and others from harm, while also acknowledging the importance of patient confidentiality in other situations.
C. "Conversations between patient and nurse are confidential." This is true, but it does not address exceptions such as harm to self or others.
D. "I can't help you unless you trust me." This does not address the patient's concerns about confidentiality directly.
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