A client is bedridden and appears to be frail and malnourished. Which nursing interventions will increase the risk of pressure injury?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Massaging the client's reddened shoulders and heels. Massaging or rubbing reddened areas can increase the risk of pressure injuries by causing friction and shearing forces on the skin, especially in individuals with compromised skin integrity. Option A, applying moisturizer to dry areas of the skin, is aimed at maintaining skin hydration and integrity, which can actually help prevent pressure injuries. Option C, cleansing the skin routinely after soiling occurs, is also a good practice to prevent skin breakdown. Option D, using a Hoyer lift for all transfers, is important for safe patient handling and does not directly increase the risk of pressure injuries. In an educational context, it is crucial for healthcare providers to understand the principles of pressure injury prevention. This includes avoiding actions that can damage fragile skin and implementing strategies to reduce pressure, friction, and shear on vulnerable areas of the body. Educating caregivers on proper skin care and transfer techniques is essential to ensure the well-being of bedridden patients.

Correct Answer: A

Rationale: In the context of multi-dimensional care, understanding a client's primary defense mechanisms against infection is crucial for healthcare professionals. The correct answer, A) Intact skin, is a fundamental barrier that prevents pathogens from entering the body. Intact skin acts as the first line of defense by physically blocking the entry of microorganisms, thereby reducing the risk of infection. Option B) Inflammation is a secondary response to infection, characterized by redness, swelling, and pain. While inflammation is part of the body's immune response, it is not the primary defense mechanism against infection. Option C) Phagocytosis is a process where immune cells engulf and destroy pathogens. Although phagocytosis plays a vital role in fighting infections, it is not the client's primary defense mechanism. Option D) Fever is a systemic response to infection that helps the body fight off pathogens by creating an inhospitable environment for them. However, fever is a secondary defense mechanism and not the primary one. Educationally, this question highlights the importance of recognizing the body's natural defense mechanisms in preventing infections. By understanding the hierarchy of defense mechanisms, healthcare providers can better assess, treat, and educate clients on infection prevention strategies. Knowledge of primary defenses like intact skin empowers healthcare professionals to promote holistic care and support optimal health outcomes for clients.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B: Provide the client with diversional activities. The psychosocial needs of a client on transmission-based precautions are crucial to address as isolation can lead to feelings of loneliness, anxiety, and depression. Providing diversional activities can help alleviate these negative emotions and enhance the client's overall well-being. Engaging the client in activities they enjoy can distract them from the stress of isolation, promote a sense of normalcy, and improve their mental health. Option A, allowing the client to sleep to build stamina, may be important for their physical health but does not directly address their psychosocial needs. Option C, maintaining a six-foot distance from the client, is a necessary infection control measure but does not focus on meeting the client's psychosocial needs. Option D, providing a timeframe for isolation, is important for managing expectations but does not actively address the client's current emotional state. Educationally, understanding the importance of addressing psychosocial needs in healthcare is vital for providing holistic care. Nurses need to consider not only the physical aspects of a client's condition but also their emotional and mental well-being to promote overall recovery and well-being. Incorporating activities that cater to a client's interests and preferences can significantly impact their experience during isolation and contribute to a more positive outcome.

Correct Answer: C

Rationale: In wound healing, the correct answer to the question is C) Inflammatory phase. This phase begins at the time of injury and typically lasts about 3-5 days. During the inflammatory phase, the body's immune response is triggered to protect against pathogens and initiate the healing process by clearing debris and bacteria from the wound site. Option A) Maturation is incorrect because it is the final phase of wound healing where the collagen fibers reorganize and strengthen the wound. Option B) Intentional is not a phase of wound healing but rather a term that implies deliberate action. Option D) Proliferative is also incorrect as it is the phase following the inflammatory phase where new tissue is generated to replace the damaged tissue. Understanding the phases of wound healing is crucial for healthcare professionals, especially those involved in wound care. Recognizing the sequence of events in wound healing helps in assessing wounds, determining appropriate interventions, and monitoring healing progress. This knowledge is fundamental in providing effective patient care and promoting optimal wound recovery.

Correct Answer: C

Rationale: In the context of preventing HIV transmission by healthcare workers, the recommended practice is to use standard precautions, which include measures like proper hand hygiene, wearing appropriate personal protective equipment (such as gloves and gowns), and safe handling of sharps. Standard precautions are designed to prevent the transmission of infections in healthcare settings by assuming that all patients could potentially have an infection, including HIV. Option A, wearing a mask within three feet of the client, is not specifically effective in preventing HIV transmission as the virus is not transmitted through the air like respiratory viruses. Option B, intentional, is a nonsensical choice and not relevant to HIV prevention. Option D, proliferative, is also unrelated to HIV transmission prevention. In an educational context, it is crucial for healthcare workers to have a clear understanding of standard precautions and their importance in infection control. By following these guidelines consistently, healthcare workers can protect both themselves and their patients from various infections, including HIV. Understanding and adhering to these practices is fundamental to maintaining a safe healthcare environment and providing quality patient care.