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) The patient must pick up the attempt right where the patient left off: Quitting smoking is a process, and a setback, such as smoking a few cigarettes, does not mean the patient must pick up where they left off as if nothing happened. The patient may need to reassess their goals, identify triggers, and modify their approach, but this setback does not mean they should immediately resume from the same spot. It’s about recognizing the challenge and continuing forward, not picking up as if no progress was made.

B) The patient will need to adapt a new lifestyle for change to be effective: While adapting to a new lifestyle is necessary for long-term success in quitting smoking, this answer overemphasizes a sudden, drastic shift. In fact, the patient may need more time in the stages of change to incorporate healthier behaviors and coping mechanisms. A lapse doesn’t automatically mean the patient has successfully adapted a new lifestyle, but it may highlight areas that need further focus.

C) The patient does not want and will never quit smoking: This assumption is not accurate. A lapse in smoking behavior does not mean the patient does not want to quit. Many individuals trying to quit smoking experience setbacks or relapses, but that does not negate their desire or ability to quit in the future. It's important to avoid labeling the patient as unwilling or incapable based on one setback.
D) The patient will return to the contemplation or precontemplation phase: This is the most accurate response. A patient who has been smoke-free but then relapses may return to the contemplation phase (where they begin to think about quitting again) or the precontemplation phase (where they are not yet actively considering quitting). The relapse does not erase the progress made but may lead to reevaluating the readiness to quit and reengaging in the quitting process with more awareness of the challenges ahead.

A. Tertiary prevention B. Primary prevention C. Health Promotion D. Secondary prevention

Correct Answer is A

Explanation

A) Tertiary prevention: Tertiary prevention involves interventions aimed at reducing the long-term effects of a disease or injury, improving quality of life, and preventing further complications. In this case, the patient is receiving rehabilitation services (physical therapy and speech therapy) after a stroke to help restore function, improve mobility, and address communication issues caused by the stroke. This type of care focuses on managing and mitigating the effects of an existing health condition, which aligns with tertiary prevention.

B) Primary prevention: Primary prevention refers to actions taken to prevent the onset of a disease or condition before it occurs, such as immunizations, lifestyle modifications, or education about healthy behaviors. Since the patient has already experienced a stroke, primary prevention is not applicable in this situation.

C) Health promotion: Health promotion involves actions that improve overall health and well-being, such as encouraging healthy lifestyles, providing education, and promoting activities that prevent illness. While health promotion is important, it is not the primary focus in this scenario, as the patient is already dealing with the aftermath of a stroke and is receiving rehabilitation to address the effects of the condition.

D) Secondary prevention: Secondary prevention involves early detection and intervention to prevent the progression of a disease or condition. It typically includes screening and diagnostic procedures to identify diseases in their early stages. Since the patient has already experienced a stroke, secondary prevention is not the appropriate level of care here.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning, what should the nurse anticipate?

Correct Answer is D

Explanation

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Explanation

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