The nurse is repositioning a patient who has a spinal injury and notes reddened areas on the heels of both feet. The nurse should place the patient in which of the following positions?

Lateral heels offloaded with pillows

Supine heels offloaded with pillows

Fowler's heels offloaded with pillows

Prone ankles offloaded with pillows.

Answer and Explanation

The Correct Answer is A

A. Lateral heels offloaded with pillows: Positioning the patient laterally with heels offloaded helps reduce pressure on the heels and prevent pressure sores.

B. Supine heels offloaded with pillows: Although offloading the heels is important, the supine position may still exert pressure on the heels and does not provide as effective offloading as the lateral position.

C. Fowler's heels offloaded with pillows: Fowler’s position may still place some pressure on the heels, even with pillows for offloading.

D. Prone ankles offloaded with pillows: The prone position is generally not recommended for patients with spinal injuries, and it does not effectively address heel pressure.

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Correct Answer is A

Explanation

A. The client with a left lower extremity fracture. Somatic pain is related to damage to body tissues, such as fractures. This type of pain is typically localized and can be acute or chronic.

B. The client with a bowel obstruction. Pain from a bowel obstruction is typically visceral rather than somatic, as it involves internal organs.

C. The client with a skin tear to the upper extremity. While this involves the skin, it is typically considered superficial somatic pain, but the context of the question suggests a deeper musculoskeletal issue.

D. The client with pneumonia. Pain from pneumonia is usually visceral due to inflammation in the lungs.

A. Decrease in muscle mass and strength B. Lower back and neck pain C. Wrinkling and sagging skin D. Joint stiffness in fingers

Correct Answer is D

Explanation

A. Decrease in muscle mass and strength: A decrease in muscle mass and strength is common with aging, known as sarcopenia. While it should be monitored, it is not necessarily an abnormal finding requiring further investigation unless it is severe or sudden.

B. Lower back and neck pain: Lower back and neck pain can be common with aging due to degenerative changes in the spine or other musculoskeletal issues. However, persistent or severe pain should be evaluated to rule out other causes.

C. Wrinkling and sagging skin: Wrinkling and sagging skin are normal aging changes related to decreased collagen and elastin in the skin. These changes are generally expected with aging.

D. Joint stiffness in fingers: Joint stiffness can be related to aging but may also indicate conditions like arthritis. If the stiffness is significant, persistent, or accompanied by other symptoms, it requires further investigation.

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The nurse is repositioning a patient who has a spinal injury and notes reddened areas on the heels of both feet. The nurse should place the patient in which of the following positions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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