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 B

Explanation

A. Acute pain: This diagnosis might be relevant if the patient has pain, but it does not address the main concern of mobility and risk related to recent falls.

B. Risk for injury: This is the most appropriate diagnosis as the patient’s inability to bear weight and recent falls increase their risk of further injury.

C. Activity Intolerance: While the patient may have activity intolerance, the more pressing concern related to their recent falls and inability to bear weight is the risk for injury.

D. Toileting self-care deficit: This diagnosis might be relevant if there were specific issues with toileting, but it is not the most appropriate for the general risk of injury due to recent falls.

A. “your children they cannot take away your driving privileges." B. "Driving is hard for older people, now you will have more time to try a new hobby." C. “This change can be difficult, let's explore alternative transportation methods" D. “Losing your privileges is awful, now you have to wait for someone else to drive you around."

Correct Answer is C

Explanation

A. “Your children, they cannot take away your driving privileges." This response is dismissive and does not address the safety concerns or explore alternative solutions. It may also ignore legal and practical considerations.

B. "Driving is hard for older people; now you will have more time to try a new hobby." This response does not directly address the individual's concerns and may come across as insensitive. It also does not explore practical alternatives for transportation.

C. "This change can be difficult; let's explore alternative transportation methods." This is the most appropriate response as it acknowledges the difficulty of the situation while offering practical support by exploring alternative transportation options.

D. “Losing your privileges is awful; now you have to wait for someone else to drive you around." This response is negative and does not provide constructive support. It may increase feelings of frustration or helplessness rather than addressing the issue constructively.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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