The nurse notes reddened areas over the hips and sacrum of a client with paraplegia from a spinal cord injury. Which action does the nurse implement?
a. Massage the reddened areas with a barrier cream.
b. Perform hip flexion and extension range-of-motion (ROM) exercises.
c. Reposition the client so that the reddened area does not bear weight.
d. Ensure that the client sits in a chair at least once each shift.
C
Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. ROM exercises are used to prevent contractures. The red-dened areas should be assessed for blanching. If the skin does not blanch, the area is vulnerable to breakdown. Appropriate interventions to relieve pressure on these areas through positioning, assistive devices, and skin protection should then be used.
You might also like to view...
A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?
A) Cure the cirrhosis. B) Treat the esophageal varices. C) Reduce fluid accumulation and venous pressure. D) Promote optimal neurologic function.
The nurse is preparing to use an otoscope to examine a patient's ear canal and drum. The patient has to be reminded to hold the head in one position. Which grip should the nurse use when examining this patient?
A) Pencil B) Hammer C) Wrench D) Handshake
Which nursing diagnosis is best for a patient with bulimia nervosa?
A) Knowledge deficit related to body weight B) Denial of condition related to need for acceptance by peers C) Cognitive impairment related to illness D) Fluid imbalance: more than body requirements
Catheters are used for which of the following purposes?
a. Promoting comfort for persons who are dying b. A convenience for the staff c. Allowing the person extra time for sleep-ing d. Treating the cause of incontinence