What is the primary reason for using a lift device when repositioning a patient with impaired mobility?
To prevent shearing of the patient's skin.
To make the repositioning process faster.
To prevent the nurse from straining their back.
To ensure the patient is positioned comfortably.
The Correct Answer is A
A. To prevent shearing of the patient's skin: When a patient is pulled or dragged across a sheet, the deeper tissues (bone and muscle) are stationary while the skin moves, leading to shear injury—one of the primary mechanisms for Deep Tissue Pressure Injuries (DTPIs). Using a lift device raises the patient completely, eliminating this destructive shearing and friction force.
B. To make the repositioning process faster: While a lift device may be efficient, patient safety and skin protection are the clinical priorities, not speed.
C. To prevent the nurse from straining their back: This is an extremely important benefit for nurse safety and injury prevention, but the primary reason the intervention is implemented in the patient's plan of care is for the direct therapeutic benefit of protecting the patient's skin integrity.
D. To ensure the patient is positioned comfortably: This is a secondary benefit. While comfort is considered, the lift device's essential function is mechanical protection of the skin and underlying tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The Braden Scale assesses six risk factors: Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction/Shear. A lower score indicates higher risk.
|
Subscale |
Patient Status |
Likely Score |
|
Mobility |
Paraplegia (Unable to change body position) |
1(Completely Immobile) |
|
Friction & Shear |
Frequently slides down in wheelchair |
2(Problem) |
|
Moisture |
Occasional moist skin |
3(Occasionally Moist) |
|
Nutrition |
Poor appetite |
2(Probably Inadequate) |
|
Activity |
Paraplegia (Bedfast or chair fast) |
2(Chairfast) |
|
Sensory Perception |
(Not specified, estimate good) |
4(No Impairment) |
|
Total Score |
1 + 2 + 3 + 2 + 2 + 4 = 14 |
A. 10-12
This range signifies a High Risk for pressure injury formation (score ≤12). While the patient is at risk, the combination of factors (paraplegia, sliding, poor nutrition) leads to a score slightly higher than this, placing them at moderate risk.
B. 16-18
This range signifies a Mild/No Risk for pressure injury. This is unlikely given the patient's severe mobility impairment (paraplegia) and issues with nutrition and shear.
C. 13-15
A Braden Score between 13 and 15 indicates a Moderate Risk for pressure injury development. Our estimated score of 14 falls directly into this range, driven by the combination of complete immobility, shear/friction, and poor nutrition.
D. 6-9
This range signifies a Very High Risk for pressure injury (≤9). This is the lowest possible range and is usually reserved for patients who are comatose, critically ill, and severely malnourished.
Correct Answer is C
Explanation
A. To promote immediate granulation tissue formation: Granulation tissue formation takes time. Tertiary intention is chosen to allow the wound to first develop healthy granulation tissue while being left open to prevent infection.
B. To ensure no scar formation occurs: Scarring will occur with tertiary intention because the wound edges are surgically brought together later, forming a larger, wider scar than primary intention. Only primary intention aims for minimal scar.
C. To decrease the risk of infection before closure: Tertiary intention is specifically chosen for wounds that are contaminated (like a traumatic accident wound) or infected. The wound is left open initially to allow for daily inspection, cleansing, and drainage, which dramatically decreases the bacterial load and risk of deep infection. Once the wound appears clean and healthy (granulating), it is surgically closed.
D. To accelerate the healing process immediately: Tertiary intention is slower than primary intention, which is immediate closure. The delay is necessary to ensure safety and prevent major infection.
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