Examkin

Soru

Zorluk: KolayBasic Care and Comfort

A nurse is developing a plan of care to maintain skin integrity and provide comfort for an older adult client who is immobile. Which of the following interventions is the most appropriate for the nurse to include?

  1. A
    Maintain the head of the bed elevated at 90 degrees for extended periods to promote comfort.
  2. B
    Delegate the initial assessment of the client's skin breakdown risk to the unlicensed assistive personnel.
  3. Use a draw sheet or friction-reducing device to lift the client when changing their position in bed.Cevap
  4. D
    Assume the client's sudden onset of urinary incontinence is a normal age-related change and solely apply absorbent briefs.

Cevap

The most appropriate intervention is to use a draw sheet or friction-reducing device to lift the client when changing their position in bed.
Using a draw sheet or a friction-reducing device allows the nurse to lift rather than drag the client across the bed linens. This intervention directly prevents friction and shearing forces, which are primary contributors to skin breakdown and pressure injuries in immobile older adults.

Adım Adım Çözüm

1
Identify the client's primary needs based on the clinical scenario.
The client is an immobile older adult, which places them at high risk for friction, shear, and pressure injuries.
Understanding the physiological risks associated with immobility guides the selection of protective care measures.
2
Evaluate the safety and physiological impact of each proposed intervention.
Lifting with a draw sheet prevents shear. Conversely, prolonged 90-degree head elevation increases shear. Delegating an initial assessment violates scope of practice. Dismissing sudden incontinence ignores potential pathology.
Basic care interventions must align with evidence-based standards for safe positioning, proper delegation, and accurate clinical judgment.
3
Select the nursing action that safely promotes comfort and skin integrity.
Using a draw sheet or friction-reducing device is identified as the correct action.
It actively protects the client's skin from mechanical damage during necessary repositioning.

Anahtar Kavram

Prevention of skin breakdown and shearing forces during bed mobility.
Bu soruyu puanla

Konular

Basic Care and Comfort

Bu konudan daha fazla soru