The client is at risk for impaired skin integrity related to the need for several weeks of bed rest. The nurse evaluates the client after one week and finds the skin integrity is not impaired. In evaluating the plan of care, what is the nurse’s best action?
Remove the nursing diagnosis in the plan of care since it has not occurred.
Keep the nursing diagnosis in the plan of care the same since the risk factors are still present.
Modify the nursing diagnosis in the plan of care to impaired skin integrity.
Change the nursing diagnosis in the plan of care to impaired mobility.
The Correct Answer is B
Choice A reason: Removing the nursing diagnosis in the plan of care since it has not occurred is not a good action, because it does not account for the possibility of future impairment. The client is still at risk for impaired skin integrity due to the prolonged bed rest, and the nurse should continue to monitor and prevent any skin breakdown.
Choice B reason: Keeping the nursing diagnosis in the plan of care the same since the risk factors are still present is the best action, because it reflects the current situation and the potential problem. The client has not developed impaired skin integrity, but the risk factors have not changed. The nurse should maintain the interventions that have been effective in preventing skin impairment, such as turning, repositioning, moisturizing, and inspecting the skin.
Choice C reason: Modifying the nursing diagnosis in the plan of care to impaired skin integrity is not a good action, because it does not match the data. The client has not shown any signs of impaired skin integrity, such as redness, blanching, breakdown, or ulceration. The nurse should not change the diagnosis based on assumptions or predictions, but on evidence.
Choice D reason: Changing the nursing diagnosis in the plan of care to impaired mobility is not a good action, because it does not address the original problem. The client may have impaired mobility due to the bed rest, but that is not the focus of the question. The question is about the risk for impaired skin integrity, which is a different issue that requires different interventions. The nurse should not ignore or replace the existing diagnosis without justification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: "In order to avoid flareups of Raynaud's, ensure to keep cool." is not a correct answer, because it can worsen the symptoms of Raynaud's phenomenon. Raynaud's phenomenon is a condition that causes the blood vessels in the fingers and toes to narrow and spasm in response to cold or stress, resulting in reduced blood flow and color changes. Keeping cool can trigger or aggravate the spasms and decrease the blood flow.
Choice B reason: "In order to avoid flareups of Raynaud's, ensure you wear sunscreen." is not a correct answer, because it is not related to Raynaud's phenomenon. Sunscreen is a protective measure for clients with lupus, who may have increased sensitivity to ultraviolet rays and increased risk of skin damage and flareups. However, sunscreen does not prevent or treat Raynaud's phenomenon, which is caused by cold or stress, not by sun exposure.
Choice C reason: "In order to avoid flareups of Raynaud's, ensure you wear gloves in winter." is a correct answer, because it can help prevent or reduce the symptoms of Raynaud's phenomenon. Wearing gloves in winter can keep the hands warm and prevent the blood vessels from narrowing and spasming due to cold. This can improve the blood flow and prevent color changes, numbness, pain, or ulcers in the fingers.
Choice D reason: "In order to avoid flareups of Raynaud's, ensure you brush your teeth for two minutes." is not a correct answer, because it is not related to Raynaud's phenomenon. Brushing the teeth for two minutes is a good oral hygiene practice that can prevent dental problems, such as plaque, cavities, or gingivitis. However, brushing the teeth does not affect the blood vessels in the fingers and toes, nor does it prevent or treat Raynaud's phenomenon.
Correct Answer is B
Explanation
Choice A reason: "Tomorrow will be better." is not a statement that demonstrates empathy, but rather one that demonstrates false reassurance or denial. False reassurance or denial is a communication barrier that dismisses or minimizes the client's feelings or concerns, and offers unrealistic or vague promises that may not be fulfilled. False reassurance or denial can make the client feel invalidated, misunderstood, or hopeless.
Choice B reason: "This must be hard news to hear. Tell me more about it." is a statement that demonstrates empathy, which is the ability to understand and share the feelings of another person. Empathy is a communication skill that acknowledges and validates the client's feelings or concerns, and invites the client to express and explore them further. Empathy can make the client feel supported, respected, and empowered.
Choice C reason: "What is your biggest fear about this diagnosis?" is not a statement that demonstrates empathy, but rather one that demonstrates probing or prying. Probing or prying is a communication barrier that asks intrusive or inappropriate questions that may make the client feel uncomfortable, defensive, or threatened. Probing or prying can make the client feel violated, judged, or pressured.
Choice D reason: "I believe you can overcome this because I've seen how strong you are." is not a statement that demonstrates empathy, but rather one that demonstrates stereotyping or labeling. Stereotyping or labeling is a communication barrier that assigns a fixed or generalized characteristic to a person or a situation, without considering the individuality or uniqueness of the person or the situation. Stereotyping or labeling can make the client feel objectified, devalued, or misunderstood.
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