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. Assess the patient's decision to ensure this is an informed and voluntary choice. B. Tell the patient that this decision is a form of suicide and is not permitted in the hospital. C. Immediately support the patient's wishes by removing food and water from the room. D. Explain to the patient that their feelings are part of the grieving process.

Correct Answer is A

Explanation

A. Assess the patient's decision to ensure this is an informed and voluntary choice. This option ensures that the patient’s choice is informed and voluntary, which is crucial for respecting patient autonomy and making sure that the decision aligns with their wishes and understanding.

B. Tell the patient that this decision is a form of suicide and is not permitted in the hospital. This response dismisses the patient’s feelings and fails to address the underlying issues. It also does not respect patient autonomy or provide compassionate care.

C. Immediately support the patient's wishes by removing food and water from the room. This action might not be appropriate without first ensuring that the decision is informed and voluntary. The patient’s needs and feelings should be fully explored first.

D. Explain to the patient that their feelings are part of the grieving process. This response might minimize the patient’s current experience and needs. While feelings of distress may be part of the process, addressing the patient’s wishes and ensuring informed consent is more crucial.

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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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