Examkin

Question

Difficulty: MediumBasic Care and Comfort

An older adult client is placed on strict bed rest due to severe generalized weakness and fragile skin. Which nursing action is most appropriate to promote comfort and prevent skin breakdown?

  1. Reposition the client using a lift sheet and limit the head of the bed elevation to 30 degrees.Answer
  2. B
    Maintain the head of the bed consistently at a 60-degree angle to facilitate resting.
  3. C
    Assign the unlicensed assistive personnel (UAP) to evaluate the sacral area for early signs of erythema.
  4. D
    Explain to the client that recent onset of urinary incontinence is an expected outcome of the aging process.

Answer

The most appropriate action is to reposition the client using a lift sheet and limit the head of the bed elevation to 30 degrees.
Limiting the head of the bed elevation to 30 degrees or less reduces shearing forces on the sacrum and coccyx. Simultaneously, using a lift sheet or draw sheet prevents skin friction during repositioning. These complementary actions are essential for maintaining skin integrity and promoting comfort in vulnerable, immobile clients.

Step-by-Step Solution

1
Analyze the client's current risk factors based on the clinical presentation.
The client is an older adult on strict bed rest with generalized weakness and fragile skin, indicating a high risk for pressure injuries caused by friction and shearing forces.
Identifying the primary physiological risks determines the priority comfort and safety interventions required in the care plan.
2
Evaluate the proposed positioning and handling techniques for safety and efficacy.
Using a lift sheet prevents skin friction, and keeping the head of the bed at or below 30 degrees prevents shearing forces on the sacrum.
Evidence-based guidelines for pressure injury prevention emphasize minimizing both shear (tissue layers sliding against each other) and friction (skin rubbing against surfaces).
3
Review the remaining options for scope of practice violations or clinical misconceptions.
Delegating skin evaluation to a UAP violates the nurse's scope of practice. Furthermore, dismissing new incontinence as normal aging ignores a potential acute pathology.
Safe nursing practice requires appropriate delegation of tasks and accurate differentiation between normal aging changes and pathological signs.

Key Concept

Pressure Injury Prevention and Safe Repositioning
Estimated Time:1m 0s
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Topics

Basic Care and Comfort

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