A client who is sitting in High-Fowler's position is at risk for what type of injury as the skin layers shift in opposite directions?

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Shearing injury. When a client is positioned in High-Fowler's position, the skin layers may shift in opposite directions due to gravity and friction. This can lead to shearing forces, where the skin is pulled in different directions, causing damage to the underlying tissues. Shearing injuries are common in individuals who are immobile or have limited mobility, as their skin is more prone to damage from these forces. Option A, Traumatic injury, is incorrect as it does not specifically relate to the shifting of skin layers in opposite directions while in a seated position. Option B, Pressure injury, is also incorrect as it refers to damage caused by pressure on a specific area of the body, not the shearing forces experienced in High-Fowler's position. Option C, Friction injury, is not the most appropriate answer as it does not capture the unique mechanism of injury associated with shearing forces. In an educational context, understanding the risks associated with different positions and their impact on skin integrity is crucial for healthcare professionals, especially those working with immobile or bedridden patients. Proper positioning techniques and regular skin assessments can help prevent shearing injuries and other complications related to immobility.

Correct Answer: D

Rationale: In providing a routine bed bath, the nurse would first cleanse the client's face for several important reasons. The face is typically the most visible and sensitive part of the body, so beginning with this area shows respect for the client's dignity and comfort. It also allows the nurse to assess the client's facial skin for any signs of irritation, infection, or other issues that may need attention. Cleansing the client's face also sets the tone for the bed bath, signaling the start of the process and helping the client to feel refreshed and rejuvenated. Additionally, washing the face before other areas helps prevent the spread of bacteria from potentially contaminated areas like the perineal region to the more sensitive facial area. Regarding why the other options are incorrect: - Cleansing the client's feet or hands first may introduce dirt or bacteria to the face, which is a more sensitive area that should be prioritized. - Cleansing the client's perineal area should be done last to minimize the risk of spreading any potential contaminants to other parts of the body, particularly the face. Educationally, this rationale underscores the importance of respecting the client's comfort and dignity, conducting a thorough assessment, and following proper hygiene protocols to ensure the client's safety and well-being during routine care procedures like bed baths.

Correct Answer: C

Rationale: In this scenario, the nurse's best response is option C) "Tell me more about that." This response is the most appropriate because it allows the mother to express her concerns and fears openly, facilitating effective communication and building a trusting relationship between the nurse and the mother. By actively listening and encouraging the mother to share her thoughts, the nurse can gain a better understanding of the mother's perspective and address her concerns in a supportive and non-judgmental manner. Option A is incorrect because it provides a directive statement without exploring the mother's concerns or offering any opportunity for discussion. This response may come off as dismissive and could potentially alienate the mother. Option B is also incorrect as it challenges the mother's beliefs rather than seeking to understand them, which could lead to defensiveness and hinder effective communication. Option D is not the best response as it shifts the focus to the nurse's personal experience rather than addressing the mother's concerns directly. This approach may minimize the mother's worries without truly acknowledging or exploring them. In an educational context, this question emphasizes the importance of active listening, empathy, and open communication in nursing practice. Nurses must create a supportive environment where patients feel comfortable expressing their concerns and fears. By using open-ended questions like the one in option C, nurses can establish rapport, gather important information, and provide individualized care that addresses the specific needs and concerns of each patient and their family.

Correct Answer: A

Rationale: The correct answer is A) Primary intention. Primary intention healing occurs when a wound is clean, well-approximated, and closed with sutures, like in the case of the abdominal incision closed with 10 sutures. This type of healing leads to minimal scar formation and faster recovery due to the edges of the wound being closely aligned, promoting efficient healing through the formation of granulation tissue. Option B) Binary intention is not a recognized term in wound healing. Secondary intention, option C), is a different process where a wound is left open to heal from the base up, often resulting in more significant scarring and a longer healing time due to the need for tissue regeneration. Understanding the different types of wound healing processes is crucial for healthcare professionals as it helps in determining appropriate wound care techniques, monitoring for signs of complications, and setting realistic expectations for the healing process with patients. This knowledge is vital in providing optimal care and promoting positive outcomes for patients undergoing surgical procedures.

Correct Answer: B

Rationale: In this scenario, the correct first action for a nurse who has been stuck by a needle is to flush the exposed skin with water. This is crucial because it helps to reduce the risk of infection by washing away any potential pathogens that may have been introduced through the needle stick. Immediate and thorough washing can significantly decrease the likelihood of transmission of infectious agents. Seeking medical attention (option A) is important, but it is not the first step. The priority is to prevent infection by cleaning the wound site promptly. Completing an incident report (option C) and reporting the exposure (option D) are necessary steps following the initial first aid and medical attention. However, they should not delay the immediate action of washing the exposed skin. In an educational context, this question highlights the importance of quick and appropriate response to occupational exposures in healthcare settings. Nurses need to be aware of the correct steps to take in the event of a needle stick injury to protect themselves and their patients from potential harm. Understanding the rationale behind each step is crucial in ensuring the safety and well-being of healthcare workers.