The RN identifies that a client is at risk for impaired skin integrity.
Which interventions should the nurse add to this client’s plan of care?
Place the patient in a side-lying position only.
Massage bony prominences.
Use positioning devices such as foam wedges.
Keep the head of the bed elevated higher than 30 degrees. E. Inspect skin every shift.
The Correct Answer is C
his intervention can help prevent pressure ulcers by reducing the amount of pressure on bony prominences and promoting blood circulation to the skin.
Choice A is wrong because placing the patient in a side-lying position only can increase the risk of skin breakdown by limiting the patient’s mobility and exposing the same areas to pressure. The patient should be repositioned frequently and encouraged to change positions if able.
Choice B is wrong because massaging bony prominences can cause tissue damage and increase the risk of skin breakdown by impairing blood flow to the area. Massaging should be avoided over bony prominences and areas of redness.
Choice D is wrong because keeping the head of the bed elevated higher than 30 degrees can cause shearing forces on the skin, which can lead to skin breakdown. The head of the bed should be kept at the lowest degree of elevation possible.
Choice E is wrong because inspecting skin every shift is not enough for a patient at risk for impaired skin integrity. The skin should be inspected at least every 2 hours or more frequently depending on the patient’s condition. Early detection of skin changes can help prevent further damage and promote healing.
Normal ranges for skin integrity are:
• Skin color: consistent with ethnicity and genetic background, no pallor, cyanosis, or jaundice.
• Skin moisture: dry to touch, no excessive perspiration or dryness. • Skin texture: smooth, soft, intact, with even surface.
• Skin temperature: warm to touch, no hyperthermia or hypothermia. • Skin turgor: elastic, returns to original shape after being pinched. • Skin integrity: no lesions, wounds, abrasions, or ulcers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.
Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.
Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.
Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.
Correct Answer is D
Explanation
The nurse has a duty to protect the patient’s rights and well-being, and to report any signs of abuse or neglect. Financial abuse is defined as someone illegally or improperly using an elder’s money or belongings for their own personal use. It is a common form of elder abuse and can have serious consequences for the victim’s physical and mental health.
The nurse should not assume that the son has the patient’s best interest in mind (choice A), as this may not be the case.
The nurse should not ignore the situation or dismiss it as a non-clinical issue (choice B), as this would violate the nurse’s ethical and legal obligations. The nurse should not notify the primary care physician that the patient can no longer care for himself (choice C), as this may not be true and may infringe on the patient’s autonomy and dignity.
The nurse should respect the patient’s wishes and help him to exercise his rights and choices.
The nurse should also provide support and resources to the patient, such as counselling, legal aid, or social services.
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