A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?

Correct Answer: A

Rationale: The most appropriate intervention for reducing the risk for a friction and shear injury in an intubated and sedated geriatric client is option A, which is to use a mechanical lift to reposition the client every 2 hours. This intervention is crucial as it helps in redistributing the pressure on the client's body, thereby reducing the risk of pressure ulcers due to friction and shear forces. Repositioning the client with a mechanical lift ensures proper body alignment and minimizes the stress on vulnerable areas, such as bony prominences, which are prone to pressure injuries. Option B, elevating the client's head of the bed to 45 degrees, is not the most appropriate intervention for reducing friction and shear injuries in this scenario. While elevating the head of the bed may have other benefits such as improving ventilation, it does not directly address the risk of pressure injuries caused by friction and shear. Option C, postponing the daily bed bath, is also not the best choice as hygiene is important in preventing infections and maintaining the client's skin integrity. Regular hygiene practices should be maintained while implementing appropriate pressure injury prevention strategies. Option D, where the caregiver independently slides the client up in the bed, is not recommended as it can increase the risk of friction and shear injuries. Improper manual handling techniques can cause friction and shear forces on the client's skin, leading to pressure ulcers. In an educational context, understanding the importance of pressure injury prevention strategies is crucial for healthcare providers caring for vulnerable populations. Proper positioning and repositioning techniques, the use of assistive devices like mechanical lifts, and regular skin assessments are essential components of quality care to prevent pressure injuries in immobilized or sedated patients.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Have client sit in a wheelchair as much as possible. This option increases the risk of pressure injuries because prolonged sitting can lead to pressure points on bony prominences, especially if the individual is unable to shift their weight or change positions frequently. This can result in decreased blood flow to the area, leading to tissue damage and the development of pressure injuries. Option A) Padding hard surfaces is actually a preventive measure that reduces the risk of pressure injuries by providing cushioning and reducing pressure on bony areas. Option C) Placing pillows between bony surfaces is also a recommended nursing intervention to prevent pressure injuries by reducing pressure and friction on vulnerable areas. Option D) Keeping the head of the bed at or less than 30 degrees is a measure to prevent aspiration in patients at risk of choking or aspiration pneumonia, and it is not directly related to the development of pressure injuries. Educationally, understanding the risk factors and preventive measures for pressure injuries is crucial for nurses caring for patients with limited mobility. It is essential to promote frequent repositioning, proper support surfaces, and pressure-relieving devices to mitigate the risk of pressure injuries and provide optimal care for patients at risk.

Correct Answer: C

Rationale: In this scenario, the nurse suspects the skin abnormality to be psoriasis. Psoriasis is a chronic autoimmune condition that speeds up the growth cycle of skin cells, leading to the formation of thick, red patches with silvery scales, commonly seen on elbows and knees. Option A, scabies, is a parasitic infestation characterized by intense itching and burrow tracks on the skin, not thick red patches with silvery scales. Option B, rosacea, is a chronic skin condition causing redness and visible blood vessels, typically on the face, not thick red patches with silvery scales on elbows and knees. Option D, stasis dermatitis, is a skin condition related to poor circulation and typically presents as swollen, discolored skin on the lower legs, not as thick red patches with silvery scales. Educationally, it is crucial for healthcare professionals to recognize common skin abnormalities like psoriasis to provide appropriate care and referrals. Understanding the distinguishing features of different skin conditions helps in accurate diagnosis and management, ensuring optimal patient outcomes. Early identification of psoriasis can lead to timely interventions and improved quality of life for the client.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Blurred vision. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) commonly used to treat rheumatoid arthritis. One of the potential adverse effects of NSAIDs, including ibuprofen, is visual disturbances such as blurred vision. Option A) Bleeding is incorrect because while NSAIDs can increase the risk of bleeding in some cases, blurred vision is a more specific adverse effect associated with ibuprofen use in this context. Option B) Insomnia and Option D) Constipation are unlikely adverse effects of ibuprofen. Insomnia is not a common side effect of NSAIDs like ibuprofen, and constipation is more commonly associated with other types of medications or health conditions. Educationally, it is important for nurses to understand the potential adverse effects of medications they administer to ensure patient safety and optimal outcomes. Teaching patients about common side effects empowers them to monitor their own health and seek appropriate medical attention if needed. It also highlights the critical role of patient education in promoting medication adherence and preventing complications.

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.