A nurse cares for older adult clients in a long-term acute care facility. Which intervention should the nurse implement to prevent skin breakdown?

Correct Answer: A

Rationale: The correct answer is A: Use a lift sheet when moving the client in bed. This intervention is crucial for preventing skin breakdown in older adults as it reduces friction and shear forces on the skin. Moving the client without a lift sheet can cause pressure ulcers. Avoiding tape (B) is important to prevent skin irritation but not specifically for skin breakdown prevention. Whirlpool therapy (C) can be beneficial for wound healing but is not directly related to preventing skin breakdown. Using loose dressings (D) may not provide adequate protection and could lead to further complications.

Correct Answer: D

Rationale: The correct answer is D because petechiae are tiny, pinpoint red or purple spots on the skin caused by bleeding under the skin. This could indicate a serious underlying medical condition such as a bleeding disorder or infection. It is crucial to discuss this immediately with the health care provider to determine the cause and initiate appropriate treatment. Choices A, B, and C are not as urgent as petechiae as they are more commonly seen in older adults and are not typically indicative of a serious medical issue requiring immediate attention.

Correct Answer: C

Rationale: The correct answer is C because applying a thick layer of corticosteroid cream can lead to overuse and potential side effects such as skin thinning. The optimal amount of cream should be applied thinly to the affected area. Choice A is correct as tepid baths can help soothe the skin before application. Choice B is correct as spreading the cream in a downward motion aligns with the direction of hair growth. Choice D is incorrect as covering the area with a dressing can enhance the absorption of the cream and improve its effectiveness.

Correct Answer: D

Rationale: The correct answer is D because lift pads help prevent friction shearing when repositioning an immobile client. Friction shearing occurs when two surfaces rub against each other, causing damage to the skin and underlying tissues. Lift pads provide a smooth surface that reduces friction, minimizing the risk of skin breakdown and pressure ulcers. Choice A is incorrect because lift pads are not designed to absorb bodily fluids. Choice B is incorrect because lift pads do not prevent diaphoresis (excessive sweating). Choice C is incorrect because the primary purpose of lift pads is not to prevent workplace injuries for staff, although they may contribute to reducing the risk of musculoskeletal injuries.

Correct Answer: C

Rationale: The correct answer is C: "Have you been deer hunting in the last week?" This question is the most appropriate because the client's symptoms of fever, chills, headache, patchy macular rash, and circular rash resembling an insect bite could indicate Lyme disease, which is commonly transmitted through deer ticks. By asking about deer hunting, the nurse can gather crucial information about potential exposure to ticks in the environment. Summary of why the other choices are incorrect: A: "Do you own dogs that stay in the yard?" - Owning dogs may be relevant for exposure to ticks but does not specifically address the client's recent activities that could have led to tick exposure. B: "Have you been working in your garden lately?" - While gardening can also lead to tick exposure, it is not as directly related to the specific symptoms presented by the client in this case. D: "Do you use sunscreen when you are outside?" - Sunscreen use is not relevant to the symptoms described and does