Nokea
The hospitalized client with limited mobility is at risk for skin breakdown. Which interventions should the nurse include in the plan of care to maintain the client's skin integrity? Select all that apply.
- A. Massage vigorously over bony prominences daily
- B. Wear sterile gloves when inspecting the client's skin
- C. Apply a moisturizing lotion to bony prominences
- D. Instruct the client to change position every 2 hours
- E. Apply an overhead trapeze to the client's bed
- F. Apply a barrier cream if the client is incontinent of stool
Correct Answer: C,D,E,F
Rationale: C: Moisturizers prevent dry skin. D: Repositioning improves circulation. E: Trapezes reduce friction during movement. F: Barrier creams protect against incontinence. A: Vigorous massage causes tissue trauma. B: Sterile gloves are unnecessary unless breakdown exists.
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A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?
- A. turning out the room light and closing the door
- B. tiring the child during the evening with play exercises
- C. identifying the child's home bedtime rituals and following them
- D. encouraging visitation by friends during the evening
Correct Answer: C
Rationale: Preschool-age children require bedtime rituals that should be followed in the hospital if possible. Choice 1 increases a child's fear. Choices 2 and 4 do not promote sleep.
A nurse is assessing a patient's right lower extremity. The extremity is warm to touch, red and swollen. The patient is also running a low fever. Which of the following conditions would be the most likely cause of the patient's condition?
- A. Herpes
- B. Scleroderma
- C. Dermatitis
- D. Cellulitis
Correct Answer: D
Rationale: Inflammation of cellular tissue associated with a fever most likely indicates cellulitis.
The LPN is receiving the report on a comatose client at the start of the shift at 1500. What statement should be of most concern?
- A. The client was repositioned on his right side at 1100.
- B. The client was bathed and skin was assessed head-to-toe at 0900 with no abnormal findings.
- C. The client's PEG tube was changed 6 months ago.
- D. The client's indwelling urinary catheter was last changed 5 days ago.
Correct Answer: A
Rationale: Bedridden clients should be repositioned every 2 hours to prevent skin breakdown.
The nurse learns at shift report that the immobile client has bilateral foot drop. Which finding during the nurse's assessment supports the presence of foot drop?
- A. The client's great toe is dorsiflexed, and the other toes are fanned out.
- B. The client's feet are unable to be maintained perpendicular to the legs.
- C. The client is unable to move the feet into a position of plantar flexion.
- D. The client is only able to dorsiflex both feet when asked to bend the feet.
Correct Answer: B
Rationale: B: Inability to hold feet perpendicular indicates foot drop. A: This describes a Babinski sign. C: Foot drop involves persistent plantar flexion, not inability to plantar flex. D: Foot drop prevents dorsiflexion.
The nurse is teaching a client about sleep and gives background information on normal sleep patterns. Which of the following substances promotes sleep?
- A. serotonin
- B. cortisone
- C. alcohol
- D. narcotics
Correct Answer: A
Rationale: Serotonin is a substance that is in the body and promotes sleep. Serotonin might play a role in synthesis of a hypnogenic factor that directly causes sleep. Drugs and alcohol can disrupt REM sleep, although they might accelerate the onset of sleep.