The practical nurse (PN) turns a client with right sided paralysis from a supine to a left lateral position. Which bony prominence is most likely to manifest signs of erythema when first turned?
Sacrum.
Ischial tuberosities.
Lateral malleolus
Iliac crest.
The Correct Answer is D
A. Sacrum: The sacrum is a common site for pressure ulcers in a supine position, but once the client is turned onto the side, pressure shifts away from the sacrum to lateral body surfaces. It is not the most at-risk area in the new position.
B. Ischial tuberosities: The ischial tuberosities bear weight when sitting, not typically when lying in a lateral position. Therefore, they are less likely to be the first site to show erythema when turned onto the side.
C. Lateral malleolus: The lateral malleolus can be at risk when the lower legs rub against the bed, but it is a smaller surface area and would show signs later compared to larger, more pressure-exposed areas like the iliac crest.
D. Iliac crest: The iliac crest on the side the client is turned onto bears significant pressure in the lateral position. It is a major bony prominence directly exposed to force against the mattress, making it the most likely site to show early erythema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "With whom have you shared your feelings?": While this question encourages emotional expression, it is more appropriate once the client is calm and ready to discuss coping strategies. Immediate emotional support is needed first.
B. "Are you having any difficulty focusing at work?": Asking about work performance is not the priority when the client is currently overwhelmed by anxiety and struggling with basic self-care. Stabilizing the client emotionally is more urgent.
C. "Would you like me to sit with you for a while?": Offering presence and emotional support helps the client feel safe and less isolated during intense anxiety. This immediate action builds trust, reduces anxiety, and prepares the client for further assessment later.
D. "Have you experienced changes in your life recently?": Life changes are important to explore, but first the client needs reassurance and stabilization. Once the client is calmer, deeper assessment about life stressors can be conducted more effectively.
Correct Answer is A
Explanation
A. A liquid nutritional supplement that contains protein: A full liquid nutritional supplement with added protein is best because protein is critical for skin integrity and tissue repair. Supplements also provide balanced calories, vitamins, and minerals necessary to support overall skin health and prevent breakdown.
B. Beef broth, or chicken broth: While broth provides fluids and some electrolytes, it is very low in calories and protein, making it insufficient alone for preventing impaired skin integrity in a client with reduced oral intake.
C. Fortified lowfat milk: Milk offers some protein and nutrients, but a specialized nutritional supplement is more calorie-dense and protein-rich, providing a more comprehensive solution for a client at risk for skin breakdown.
D. Apple or grapefruit juice: Fruit juices offer hydration and some vitamins but lack significant protein and calories. They are inadequate for maintaining skin integrity, especially when protein intake is a primary concern.
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