The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. Which is the best method for repositioning the patient?

Slide the patient into the new position

Place the patient in a 30 degree supine position.

utilize a transfer device to lift the patient.

Elevate the head of the bed 45 degrees

Answer and Explanation

The Correct Answer is C

A) Slide the patient into the new position: Sliding a patient when repositioning can create shear forces on the skin, which may contribute to skin damage. Shearing can occur when the skin sticks to the surface while the underlying tissues move, leading to increased risk of pressure ulcers. Therefore, sliding is not considered the most effective or safest way to reposition a patient at risk for skin impairment.

B) Place the patient in a 30-degree supine position: Placing the patient in a 30-degree supine position is a good method for reducing pressure on bony prominences and minimizing the risk of pressure injuries. However, while this position is helpful for preventing skin breakdown, it does not address the method of repositioning, which is what is being asked in this question.
C) Utilize a transfer device to lift the patient: Using a transfer device, such as a lift or slide sheet, to lift the patient is the best method for repositioning. This technique helps to reduce friction and shear forces on the skin, providing a safer and more effective way to move the patient without causing damage. Transfer devices also allow for a smoother repositioning, minimizing the risk of skin impairment.

D) Elevate the head of the bed 45 degrees: Elevating the head of the bed to 45 degrees can increase the risk of pressure injuries, especially if the patient is immobile and cannot relieve pressure themselves. This position can also contribute to shear forces as the patient slides downward. It may be appropriate in certain clinical situations, but it does not directly address the method of repositioning.

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Correct Answer is D

Explanation

A) Contractures developed: The development of contractures indicates a lack of proper joint movement or stretching, which can occur if passive range-of-motion (ROM) exercises are not performed appropriately. Contractures are an undesirable outcome that occurs when joints or muscles become stiff and shortened, which hinders mobility. The goal of passive ROM exercises is to prevent this, so the development of contractures would indicate failure to meet the goal.

B) Muscle strength improved: Passive range-of-motion exercises do not directly improve muscle strength. They are designed to maintain joint flexibility and prevent complications like contractures in individuals who are unable to move their limbs actively. Strengthening muscles typically requires active participation, which would be more effectively addressed with active ROM exercises or resistance training as appropriate.

C) Heart rate decreased: While physical activity can influence heart rate, passive ROM exercises primarily aim to maintain joint mobility and prevent complications like contractures. A decrease in heart rate would not be an indicator of successful passive ROM exercises. The focus here is on joint flexibility and prevention of stiffness, rather than cardiovascular effects.

D) Joint mobility maintained: Successful goal achievement in passive range-of-motion exercises is indicated by the maintenance of joint mobility. These exercises help prevent the stiffening of joints, preserve range of motion, and promote circulation. If the patient’s joint mobility is maintained, it shows that the passive ROM exercises are effectively preventing contractures and promoting the best possible outcome for the patient’s condition.

A. Focusing on helping patients be disease free B. Providing care that involves the whole person C. Assuring that care is strictly personal in nature D. Directing focus only on the pathological state

Correct Answer is B

Explanation

A) Focusing on helping patients be disease free: The World Health Organization (WHO) definition of health goes beyond the absence of disease. It emphasizes the complete state of physical, mental, and social well-being, rather than simply the absence of illness. Focusing solely on being disease-free does not align with this holistic view of health.

B) Providing care that involves the whole person: This is the correct approach in line with the WHO definition of health. WHO defines health as a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. Therefore, the nurse should focus on addressing all aspects of a person’s health, including emotional, social, and physical needs, to promote overall well-being.

C) Assuring that care is strictly personal in nature: While personal care is important, the WHO definition of health emphasizes a broader, more holistic approach that incorporates physical, mental, and social aspects of health, not just personal care. It’s about treating the whole person in context, including their environment and social relationships.

D) Directing focus only on the pathological state: The WHO definition moves beyond just focusing on the pathological (disease) state and emphasizes wellness in all aspects of life. While addressing medical issues is important, focusing solely on pathology ignores the broader concept of health that includes mental and social well-being.

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The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. Which is the best method for repositioning the patient?

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