A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces?
a. Administer pain medication every 4 hours as needed.
b. Turn the patient every 2 hours, even hours.
c. Monitor vital signs, especially rhythm.
d. Keep the bed side rails up at all times.
ANS: B
The most appropriate intervention for the diagnosis of Impaired skin integrity is to turn the patient. Choose interventions to alter the etiological (related to) factor or causes of the diagnosis. The other options do not directly address the shearing forces. The patient may need pain medication, but Acute pain would be another nursing diagnosis. Monitoring vital signs does not have when or how often these should be done. Keeping the side rails up addresses safety, not skin integrity.
You might also like to view...
An older woman tells the nurse that she has experienced increasing fatigue and shortness of breath over the last 2 days. Which goal is the nurse's priority?
a. Promote safety to prevent injury. b. Complete nutritional assessment. c. Balance exercise and rest periods. d. Explore the woman's complaints.
A patient with Parkinson's disease informs you
that the stiffness and slowness of movements associated with the illness have become worse. What should you teach the patient about this change? a. "These changes are normal and expected as your disease progresses." b. "You will need to use a walker at all times to avoid falls and accidents." c. "Whenever your symptoms worsen, contact your prescriber right away." d. "If your prescriber increases your drug dosage these functions will improve."
What ligament holds the ovaries in place?
A) Infundibuloabdominal B) Pelvic C) Round D) Infundibulopelvic
A patient is being treated for prostate cancer; his prognosis is very poor. The patient has a strong faith, and he has been active in his church for many years. He is concerned about his health and the challenges he faces as his cancer progresses
Which comment by the nurse reflects the most appropriate spiritual nursing intervention for the patient? A) "I'll take you to visit my church if you can get a pass." B) "You have to belong to the same church I do if you're going to go to heaven." C) "Would you like me to bring you a guided imagery audiotape?" D) "We can pray together if you'd like."