A nurse is caring for a client who has a diagnosis of Impaired skin integrity, related to immobility, secondary to neurologic dysfunction. Which should the nurse identify as an observation intervention?

Question

1. Turn and reposition client every 2 hours.
2. Cushion bony prominences with soft foam while in bed.
3. Provide ongoing assessment for skin breakdown every shift.
4. Apply lotion to dry skin twice daily.

Answer 1

Correct Answer: 3
Rationale 1: Prevention interventions prescribe the care needed to avoid complications or reduce risk factors. Turning and repositioning would help prevent any further skin breakdown.
Rationale 2: Prevention interventions prescribe the care needed to avoid complications or reduce risk factors. Cushioning bony prominences would help prevent any further skin breakdown.
Rationale 3: Observations include assessments made to determine whether a complication is developing as well as observations of the client's responses to nursing and other therapies. Assessment for skin breakdown would fall under this category.
Rationale 4: Application of lotion or other treatments to areas of skin impairment would be considered a treatment intervention.