The nurse is caring for a patient admitted with weakness and has a history of osteoporosis and obesity. What nursing intervention should the nurse implement while providing hygiene care?
Inspect the patient's feet for a diabetic ulcer.
Expose the full body to ensure efficiency.
Encourage the patient to provide self-care.
Apply baby powder to the perineal area and skin folds.
The Correct Answer is C
A. Inspect the patient's feet for a diabetic ulcer: Patients with obesity are at increased risk for skin breakdown, and foot ulcers may go unnoticed. Early detection prevents complications.
B. Expose the full body to ensure efficiency: Patients should be kept covered as much as possible to maintain dignity, privacy, and body temperature.
C. Encourage the patient to provide self-care: If the patient is able, self-care promotes independence and helps maintain mobility.
D. Apply baby powder to the perineal area and skin folds: Powder can clump and retain moisture, leading to skin irritation and fungal infections, especially in skin folds.
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Related Questions
Correct Answer is D
Explanation
A. Apply restraints to the patient's wrists. Restraints should be a last resort and only used when all other interventions have failed. Before restraining, less restrictive methods such as reorientation, supervision, and environmental modifications should be attempted first.
B. Turn on the patient’s bed alarm. While a bed alarm can alert staff if the patient attempts to get out of bed, it does not prevent the patient from pulling at their dressings and IV lines. More direct supervision is needed.
C. Administer a sedating medication. Sedation should be used cautiously, as it may increase the risk of falls, delirium, and respiratory depression. Non-pharmacologic interventions should be attempted first unless the patient is a danger to themselves or others.
D. Move the patient closer to the nurse’s station. This is the best first intervention. Placing the patient closer to the nurses' station allows for increased supervision and quicker intervention while also helping to reduce agitation through reassurance and reorientation.
Correct Answer is A
Explanation
A. Assess the patient: The priority action is to assess the patient for injuries before taking any further steps.
B. File a safety event report: This is important but should be done after assessing and ensuring the patient’s safety.
C. Place the patient on fall precautions: While necessary, this is a secondary intervention after assessment and ensuring immediate safety.
D. Get the patient back to bed: Moving the patient before assessing for injuries could worsen potential fractures or other injuries.
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