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. Cancer pain: Cancer pain can result from tumor growth, tissue invasion, or nerve compression caused by cancer. It can be acute or chronic and may vary in intensity. However, in this scenario, the client's pain is specifically associated with dermatitis resulting from radiation therapy, rather than directly from the cancer itself.

B. Acute pain: Acute pain is typically sudden in onset and is often associated with tissue injury or damage. In this case, the painful dermatitis resulting from radiation therapy would be considered acute pain because it is directly related to the recent tissue damage caused by the radiation. Acute pain is usually short-term and resolves as the underlying cause heals or is treated.

C. Chronic pain: Chronic pain persists beyond the expected time for tissue healing and is often associated with conditions such as arthritis or neuropathy. While cancer pain can sometimes become chronic if it persists over time, the pain described in this scenario is more likely to be acute given its association with recent radiation therapy.

D. Neuropathic pain: Neuropathic pain results from damage or dysfunction of the nervous system and can present as shooting or burning sensations. While neuropathic pain can occur in cancer patients, the pain described in this scenario is more likely to be acute and related to tissue damage from radiation therapy rather than neuropathy.

A. Chocolate milk B. Diet cola C. Brewed iced tea D. Lemon-lime soda

Correct Answer is D

Explanation

A. Chocolate milk:
Chocolate contains caffeine, which can contribute to sleep disturbances. It is not a recommended beverage for someone looking to decrease caffeine intake.

B. Diet cola:
Cola contains caffeine, even in diet versions, which can contribute to sleep disturbances. Therefore, it is not suitable for decreasing caffeine intake.

C. Brewed iced tea:
Brewed iced tea contains caffeine, which can interfere with sleep. It is not a suitable option for someone trying to reduce caffeine consumption.

D. Lemon-lime soda:
Lemon-lime sodas typically do not contain caffeine, making them a better choice for someone looking to reduce their caffeine intake and improve sleep.

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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

A nurse is caring for a client who had radiation therapy and is experiencing painful dermatitis. The nurse should identify the client is experiencing which of the following types of pain?

Correct Answer is A

Explanation

A nurse is educating a client who is experiencing sleep disturbances and desires to decrease caffeine intake. Which of the following beverages should the nurse recommend?

Correct Answer is D

Explanation

Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 45 mq, calcium 45 mg/dL?

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

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