The nurse is caring for a client in the emergency department with diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso
For which action, made by the nurse aide, would the nurse provide further instruction? A) The nurse aide used mild soapy water to clean the face.
B) The nurse aide moved the client's head to clean behind the ears.
C) The nurse aide cleaned the eye area from the inner to outer eye area.
D) The nurse aide cleaned the neck and upper chest area.
B
Feedback:
Further instruction would be provided to the nurse aide when the nurse aide attempted to move the client's head to clean behind the ears. There should be no movement of the client's head when there is a history of head trauma. Cleaning the client's face with soapy water, cleaning the eye area, and cleaning the neck and upper chest are all appropriate actions completed by the nurse aide.
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