The nurse is supervising care for an 82-year-old client who has had dementia for 15 years. Presently, the client is non-communicative and has very limited mobility. The nurse cautions the unlicensed assistive personnel (UAP) to be very cautious and gentle when repositioning the client. What is the priority physiological reason for the nurse's guidance?

to prevent skin breakdown

to ensure the client's comfort

to decrease the risk of pathological fractures

to reduce the client's energy requirement with motion

Answer and Explanation

The Correct Answer is C

A. to prevent skin breakdown: While repositioning is essential for preventing decubitus ulcers, the instruction to be "gentle" specifically addresses mechanical force rather than frequency of turning. Skin breakdown is managed by pressure relief schedules and moisture control. It does not primarily relate to the risk of structural skeletal failure during handling.

B. to ensure the client's comfort: Maintaining comfort is a fundamental nursing goal, but it is a subjective psychosocial outcome rather than a priority physiological reason. In a non-communicative patient with advanced dementia, physiological safety takes precedence. Gentle handling is a safety intervention to prevent acute physical injury during routine care.

C. to decrease the risk of pathological fractures: Chronic immobility and advanced age lead to profound disuse osteoporosis and decreased bone mineral density. In such fragile states, even minor torsional or shearing forces during repositioning can result in a fracture. Gentle handling is required to protect the demineralized skeletal system from mechanical trauma.

D. to reduce the client's energy requirement with motion: Passive repositioning by staff does not significantly impact the client’s metabolic rate or total energy expenditure. The energy required for this motion is provided by the caregiver rather than the patient. This physiological factor is irrelevant to the safety precautions needed for an immobile geriatric patient.

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Correct Answer is C

Explanation

A. That much ibuprofen should relieve your pain: This response is dismissive of the client's subjective experience of pain and fails to address safety. Pain threshold and intensity vary among individuals regardless of standard dosing. It lacks the necessary education regarding the maximum daily limits of the medication.

B. You probably should ask your healthcare provider if it is acceptable: While referring to a provider is necessary, this response is too passive and misses an immediate teaching opportunity. The nurse must identify the specific safety risk associated with the current dosage. It does not provide the rationale for the referral.

C. That amount is greater than the recommended daily amount. Discussing your increased pain with your healthcare provider is important: Doubling 400 mg every 4 hours results in 4800 mg daily, exceeding the 3200 mg maximum safe limit. This creates a high risk for gastrointestinal erosion and renal toxicity. The nurse must prioritize patient safety through education and provider consultation.

D. Ibuprofen is eliminated by the kidneys. It would be important for your healthcare provider to order BUN and creatinine levels to determine if the increased dose is safe: This focuses on diagnostic monitoring rather than the immediate danger of exceeding the maximum daily dose. While renal function is relevant, the priority is preventing toxicity by correcting the dosage. Staging the response around lab tests delays the necessary intervention.

A. "I will pack the wound with NSS soaked gauze every other day until my next appointment." B. "I will increase my daily intake of foods such as almonds, eggs, and chicken." C. "I will apply Santyl ointment daily to the peri-wound to moisturize!" D. "I should stay in my wheelchair for all meals and activities."

Correct Answer is B

Explanation

A. "I will pack the wound with NSS soaked gauze every other day until my next appointment.": Wet-to-dry dressings are often contraindicated for Stage 2 injuries as they can damage fragile regenerating epithelial tissue. Furthermore, packing should be done daily if used, as "every other day" allows the dressing to dry and adhere. This reflects poor wound care technique.

B. "I will increase my daily intake of foods such as almonds, eggs, and chicken.": Protein is essential for collagen synthesis and tissue repair in chronic pressure injuries. Almonds, eggs, and chicken provide high-quality amino acids necessary for the proliferative phase of healing. Nutritional optimization is a cornerstone of successful long-term wound management.

C. "I will apply Santyl ointment daily to the peri-wound to moisturize!": Santyl is a collagenase enzyme used for debriding necrotic tissue, not for moisturizing healthy skin. Applying it to the peri-wound area can cause significant skin irritation and maceration. It should only be applied directly to the wound bed if slough is present.

D. "I should stay in my wheelchair for all meals and activities.": Remaining seated for extended periods increases sustained pressure on the sacrum, which caused the initial injury. Patients with sacral ulcers must be taught to offload pressure every 15 minutes while seated. Continuous sitting would impede blood flow and prevent the wound from healing.

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Naxlex Comprehensive Predictor Exams

A client tells the nurse that the arthritis pain is not relieved by 400 mg of ibuprofen every 4 hours, so the client doubles the dose. What is the nurse's best response?

Correct Answer is C

Explanation

The client presents to the wound care clinic with a stage two pressure injury to the sacrum. The wound has been treated in the clinic for three months. Which statement by the client indicates to the nurse that teaching has been effective during this clinic visit?

Correct Answer is B

Explanation

A hospice client has been prescribed an opioid for the past 6 months for pain control. The nurse contacts the healthcare provider because the dosage of the opioid no longer provides pain relief. What is the reason for this nontherapeutic response to the opioid?

The nurse is teaching the mother of a 2-year-old client how to administer ear drops. The nurse recognizes correct return demonstration by the mother upon observing which technique?

A client will be discharged with a 1-week supply of the combination medication of oxycodone and acetaminophen for pain management after abdominal surgery. Which statement by the client indicates to the nurse that teaching about self-administration of this analgesic was effective?

The nurse has identified the following findings upon assessment of a client's left lower leg wound: copious amounts of drainage and pain relief with elevation. How would the nurse identify this wound in documentation?

The nurse is caring for a client who is experiencing chronic pain from metastatic cancer. Which principle of pain management is most effective for this client?

The nurse notes these medications for a post-operative client. Which order would the nurse question?

An adult client is discussing experiencing occasional episodes of insomnia. In assessing the client's approach to sleep, which client statement should the nurse discuss further with the client?