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In caring for a quadriplegic client which action would the nurse implement to prevent skin breakdown?

Reposition the client every 2 hours.

Apply compression stockings.

Ambulate the client at least once per shift.

Perform hourly skin checks.

Answer and Explanation

The Correct Answer is A

A. Repositioning every 2 hours is a standard intervention to prevent pressure ulcers and promote circulation.

B. Compression stockings are used for preventing DVTs but do not directly prevent skin breakdown.

C. Ambulation is not feasible for a quadriplegic client.

D. Hourly skin checks can be beneficial but are secondary to preventive measures like repositioning.

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Correct Answer is D

Explanation

A. A closed fist is used for assessing deeper structures, such as kidney tenderness, not the sinuses.

B. The hyperextended middle finger is typically used for indirect percussion, not direct.

C. The palm is not suitable for sinus percussion as it covers a large area and reduces sensitivity.

D. The fingertips of the dominant hand are best for direct percussion of the sinuses to assess for tenderness or fluid accumulation.

A. Document the findings as a vernix caseosa and is consider it normal. B. Report the parents to the department of children and families. C. Educate the parents that the findings are normal and should fade away by the age of three. D. Notify the healthcare provider.

Correct Answer is C

Explanation

A. Documenting the findings is also important, but it should be noted as Mongolian blue spots rather than vernix caseosa.
B. Reporting the parents to the department of children and families would be inappropriate, as Mongolian blue spots are not a sign of abuse or neglect
C. Mongolian blue spots, also known as congenital dermal melanocytosis, are benign skin markings that are usually present at birth or appear shortly after. They are more common in individuals with darker skin tones and are not indicative of any disease or disorder.
D. While it is always prudent to notify the healthcare provider of any findings, in the case of Mongolian blue spots, no immediate medical intervention is necessary.

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In caring for a quadriplegic client which action would the nurse implement to prevent skin breakdown?

Nursing Test Bank

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