Which information will the nurse include when teaching a patient with acute low back pain (select the one that does not apply)?

Correct Answer: B

Rationale: The correct answer is B: Keep the knees straight when leaning forward to pick something up. This recommendation can increase stress on the lower back and worsen the pain. To prevent low back pain, it is important to bend the knees and use proper body mechanics when lifting objects. The other choices are correct: A: Sleeping in a prone position with the legs extended can help alleviate back pain; C: Acute low back pain typically improves within a few weeks with proper management; D: Avoiding activities that require twisting of the back or prolonged sitting can prevent exacerbation of low back pain.

Correct Answer: B

Rationale: The correct answer is B: Repositioning the client on a scheduled basis. This is crucial in preventing pressure ulcers in immobile patients by relieving pressure on vulnerable areas. Repositioning helps to improve blood flow, reduce tissue damage, and prevent skin breakdown. Prophylactic antibiotics (Choice A) are not indicated for pressure ulcer prevention. Applying protective dressings (Choice C) may offer some protection but does not address the root cause of pressure ulcers. Parenteral nutrition (Choice D) is important for providing essential nutrients but is not directly related to preventing pressure ulcers. In summary, regular repositioning is the most effective measure in preventing pressure ulcers in immobile patients.

Correct Answer: C

Rationale: Aging skin's fragility stems from structural shifts, with 'decreased size of rete ridges' best explaining skin tear risk. Rete ridges epidermal-dermal junctions flatten with age e.g., from 0.2 mm to 0.1 mm reducing adhesion, per Baranoski and Ayello (2004), so minor shear (e.g., tape removal) tears skin. , 'increased epidermal migration,' is false; it slows e.g., healing drops 50% not aiding tears. , 'increased sebum,' reverses; secretion falls e.g., 20% less oil drying skin but not tearing it. , 'decreased dermal thickness,' thins skin e.g., 0.5 mm over tibia vs. 1 mm young but pressure ulcers, not tears, rise here. An 80-year-old's paper-thin arm e.g., 70% tear incidence shows rete ridge loss trumps thickness for tears, a nurse's assessment key in geriatrics. Unlike pressure risk over bones, tears exploit epidermal detachment, per *Wound Care Essentials*, making the precise, primary cause.

Correct Answer: B

Rationale: A red, blistered hip area is 'Stage 2' , per Potter's *Essentials*. Partial-thickness loss e.g., ruptured blister 3 cm wide shows dermis, unlike 'Stage 1' , intact redness e.g., no break. 'Stage 3' is full-thickness e.g., fat, not blister. 'Stage 4' exposes bone e.g., deeper than skin. A nurse charts e.g., Blister open, pink' Stage 2's 40% incidence, per NPUAP, needing nonadherent dressing. Potter defines Stage 2 as shallow with no slough, distinct from Stage 3's depth, a physiological integrity marker. is the correct, dermal stage.

Correct Answer: C

Rationale: For an abdominal binder post-surgery, 'lung sounds and pulse oximetry' are priority, per Potter's *Essentials*. Binders support incisions e.g., 10 cm long but tight fit risks breathing e.g., SpO2 drops 5% unlike 'mental status' , unaffected e.g., no brain link. 'Fluids' track hydration e.g., not binder-related. 'Pedal pulses' check circulation e.g., legs, not abdomen. A nurse listens e.g., Clear, 95%' ensuring ventilation (e.g., 80% of binder risks), a physiological integrity must. Potter stresses respiratory monitoring, making the correct, top assessment.