A client's spouse reports the presence of a reddened area on the client's coccyx and wants to massage the area. Which response by the nurse is appropriate?
A) "I will need to obtain an order from the healthcare provider to perform a massage."
B) "Massaging the area twice daily will help restore circulation and should be incorporated into the plan of care."
C) "I will record these findings in the medical record."
D) "Massaging the area may actually cause more harm to a potentially compromised area of skin."
Answer: D
The presence of redness may indicate the presence of a stage I pressure ulcer. Massage can cause a friction-like response to compromised skin and should be restricted when problems are noted. Massages, when therapeutic, do not require a healthcare provider's order.
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