Which activity should the nurse implement to decrease shearing force on a client's stage Il pressure injury?

pulling the client up from under the arms

improving the client's hydration

lubricating the area with skin cream

preventing the client from sliding in bed

Answer and Explanation

The Correct Answer is D

A) Pulling the client up from under the arms: This action can increase shearing force on the client's skin, especially if done abruptly or without proper assistance. Pulling the client up by the arms can create friction and shear between the skin and underlying tissues, potentially worsening the pressure injury.
B) Improving the client's hydration: While hydration is essential for overall skin health, it is not directly related to reducing shearing force on a pressure injury. Hydration can help maintain skin integrity and promote healing but does not directly address the mechanical forces contributing to pressure injuries.
C) Lubricating the area with skin cream: While skin cream can help moisturize and protect the skin, it may not necessarily reduce shearing force on a pressure injury. While lubrication can reduce friction between surfaces, it may not be sufficient to prevent shearing forces that occur during movement or repositioning.
D) Preventing the client from sliding in bed: This is the most appropriate action to decrease shearing force on a stage II pressure injury. Sliding in bed can exacerbate shearing forces on the skin, leading to further damage or delayed healing of the pressure injury. Using devices such as pillows, positioning aids, or specialized mattresses can help prevent the client from sliding and minimize shearing forces on the affected area, promoting healing and preventing further injury.

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Correct Answer is A

Explanation

A) The client's hand is cool and pale: A cool and pale hand suggests decreased circulation, which could be due to the restraint being too tight and impeding blood flow. Loosening the restraint can improve circulation and prevent complications such as tissue damage or nerve injury.
B) The client has full range of motion in her wrist: While it's important to ensure that the client can move comfortably within the restraint to prevent stiffness and maintain circulation, full range of motion alone may not necessitate loosening the restraint. However, if the client's movements are restricted or uncomfortable due to the tightness of the restraint, loosening may be necessary.
C) The client is attempting to remove the restraint: This indicates that the restraint may be too loose or improperly applied, allowing the client to manipulate it easily. The nurse should assess the fit of the restraint and adjust it as needed to prevent the client from removing it while still ensuring safety and appropriate immobilization.
D) The client has a capillary refill of less than 2 seconds: While a rapid capillary refill indicates good circulation, it alone may not warrant loosening the restraint. However, if the client experiences discomfort or other signs of impaired circulation despite rapid capillary refill, the restraint may need adjustment to alleviate pressure and improve circulation.

A. Halitosis B. Sordes C. Bruxism D. Xerostomia

Correct Answer is C

Explanation

A) Halitosis: Halitosis refers to bad breath, which may or may not be related to bruxism. While teeth grinding can contribute to dental issues that may lead to halitosis, it is not the primary disorder associated with teeth grinding.
B) Sordes: Sordes refers to the accumulation of foul-smelling crusts or deposits around the teeth and gums, typically seen in individuals with poor oral hygiene or compromised oral health. It is not directly related to teeth grinding.
C) Bruxism: Bruxism refers to the habit of grinding or clenching the teeth, especially during sleep. It can lead to dental problems, jaw pain, headaches, and other issues related to the temporomandibular joint (TMJ). Referring the client to a dentist for evaluation and management of bruxism is appropriate to address the underlying dental concerns associated with teeth grinding.
D) Xerostomia: Xerostomia, also known as dry mouth, is a condition characterized by reduced saliva production. While xerostomia may exacerbate dental problems and contribute to oral discomfort, it is not specifically associated with teeth grinding.

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Which activity should the nurse implement to decrease shearing force on a client's stage Il pressure injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

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