A patient with a brain injury is not able to respond appropriately to sensory stimulation. What should the nurse do to ensure that this patient does not develop skin breakdown? (Select all that apply.)

Question

a. Protect bony prominences
b. Assess the skin every 2 hours
c. Moisturize the skin as needed
d. Apply paper tape over wounds
e. Turn and reposition every 2 hours

Answer 1

ANS: A, B, C, E
To protect the skin of a patient with an alteration in sensation, the nurse should protect bony prominences, assess the skin every 2 hours, moisturize the skin as needed, and turn and reposition the patient every 2 hours. D. Paper tape can adhere to delicate skin tissue and cause tears.