Saunders Mobility, Hygiene and Skin Integrity
A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds, knowing that which would most likely result from this improper crutch measurement? 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired range of motion while the client ambulates
Answer: 2 Rationale: Crutches are measured so that the tops are 2 to 3 finger widths from the axillae. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the crutch, which could result in injury to the nerves of the brachial plexus. Although the conditions in options 1, 3, and 4 can occur, they are not the most likely result from resting the axilla directly on the crutches.
9. The nurse is teaching a client with right-sided weakness related to a stroke about how to properly ambulate with a cane. Which client action would indicate a need for further teaching? 1. The client holds the cane on the right side of the body. 2. The client moves the weaker leg toward the cane first. 3. The client holds the cane 6 inches laterally from the foot. 4. The client keeps two points of support on the floor at all times
Answer: 1 Rationale: Canes are assistive devices used to support clients with one-sided weakness or partial or complete leg paralysis. Canes are lightweight and easily movable. The cane needs to be held on the stronger side of the body and 4 to 6 inches laterally from the foot. While walking, the client needs to advance the cane forward 6 to 10 inches while keeping bodyweight distributed on both lower extremities. The client would then move the weaker leg forward toward the cane to distribute body weight between the cane and the stronger leg. Then, the client advances the stronger leg past the cane. Remind the client to keep two points of support on the floor at all times to prevent falls. Therefore, since the cane needs to be held on the stronger side of the body and this client has right-sided weakness and is holding the cane on the right side, option 1 is the answer that requires a need for further teaching from the nurse.
The nurse is performing a skin assessment on a client and notes an area of full-thickness loss of skin on the sacrum. Adipose tissue and granulation tissue are present with no visible muscle, tendon, ligament, cartilage, or bone. How would the nurse classify this pressure injury? 1. Stage 1 pressure injury 2. Stage 2 pressure injury 3. Stage 3 pressure injury 4. Stage 4 pressure injury
Answer: 3 Rationale: A stage 3 pressure injury is characterized by fullthickness skin loss in which adipose tissue is apparent with slough or eschar. There may also be granulation tissue and rolled wound edges. There is no exposed fascia, muscle, tendon, ligament, cartilage, or bone; this would be noted in a stage 4 pressure injury
The nurse is reviewing dental care with a client who is edentulous and wears dentures. Which client statement indicates an understanding of proper dental care? 1. "Since I have no teeth, I do not need to brush my mouth." 2. "I need to use hot water when cleaning my dentures to kill bacteria." 3. "I will remove my dentures before bed and keep them in my labeled denture cup covered with water." 4. "When I am not wearing my dentures during the day, I can keep them in the denture cup with no water, as they should only be in water at night."
Answer: 3 Rationale: Denture care and oral hygiene are important in the care of the edentulous client who wears dentures. Clients may think that since they no longer have teeth, they no longer need to brush their gums. Educate clients that proper brushing is still essential to maintain good gum health. Therefore, option 1 is incorrect. Dentures need to be cleaned on a regular basis to avoid gingival infection and irritation. Whenever the dentures are removed, they need to be stored in the client's labeled denture cup and covered with water to prevent drying out and warping of the dentures. Therefore, option 4 is incorrect. Dentures need to be cleaned in lukewarm, or tepid, water to prevent damaging or warping the dentures. Therefore, option 2 is incorrect. Option 3, the correct answer, indicates client understanding, as dentures need to be removed at night to provide the gums rest and prevent bacteria buildup. The dentures need to be stored in the client's labeled denture cup and covered with water.
10. The nurse is preparing a list of client care activities to be done during the shift. For which clients would the nurse instruct the assistive personnel (AP) to use an electric razor for shaving? Select all that apply. 1. A client with leukocytosis 2. A client with thrombocytosis 3. A client with thrombocytopenia 4. A client receiving an antiplatelet medication 5. A client receiving acetaminophen as needed for mild pain
Answer: 3, 4 Rationale: Electric razors need to be used for clients who are at risk for bleeding, which include clients with thrombocytopenia (a low platelet level), clients with bleeding or clotting disorders, and clients taking certain medications, such as antiplatelet and anticoagulation medications. Therefore, options 3 and 4 are correct. Leukocytosis is not related to bleeding risk, as this indicates an elevated white blood cell count. Thrombocytosis indicates a higher-than-normal platelet level, which increases the risk for clotting. Finally, acetaminophen is not a medication that increases the client's risk for bleeding.
The nurse in a long-term care facility is observing a nursing student provide foot care to a client with diabetes mellitus. Which action by the nursing student would indicate a need for further teaching? 1. The nursing student tells the client to avoid soaking the feet. 2. The nursing student dries the feet thoroughly, including in between the toes. 3. The nursing student advises the client to consult the physician or a podiatrist regarding nail trimming. 4. The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes.
Answer: 4 Rationale: Clients with diabetes mellitus are at an increased risk for impaired skin integrity related to peripheral neuropathy or vascular insufficiency. The feet are at an increased risk for the development of wounds and some clients may be unable to thoroughly inspect the feet regularly due to impaired mobility or other impairments. Meticulous foot care is necessary to prevent complications. The client's feet would not be soaked to prevent maceration, or skin softening, as this increases the risk of infection. Regarding nail trimming, a podiatrist or a physician's order may be necessary to trim the nails, as a client with diabetes mellitus is at increased risk for infection if the skin were to be accidentally cut. The feet need to be dried thoroughly, with special attention given to the areas between the toes, as skin breakdown or ulcers can go undetected in this area. Lotion needs to be applied to the dorsal and plantar surfaces of the foot. However, it would not be applied between the toes as this area needs to be kept dry. Therefore, option 4 is the action by the nursing student that requires a need for further teaching.
The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage 2 pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? 1. Intact skin 2. Full-thickness skin loss 3. Exposed bone, tendon, or muscle 4. Partial-thickness skin loss with exposed dermis
Answer: 4 Rationale: In a stage 2 pressure injury, the skin is not intact. Partial-thickness skin loss with exposed dermis is present. It presents with a viable red-pink and moist wound bed. It may also present as an intact or ruptured serum-filled blister. The skin is intact in stage 1. Full-thickness skin loss occurs in stage 3. Exposed bone, tendon, or muscle is present in stage 4.
The nurse is preparing to provide wound care to a client with a stage 1 pressure injury. Which dressing would the nurse expect to be prescribed in the treatment of this wound? 1. Hydrogel dressing 2. Transparent dressing 3. Antimicrobial dressing 4. Calcium alginate dressing
Answer: 2 Rationale: A stage 1 pressure injury is characterized by intact skin with nonblanchable erythema. Dressings used to manage a stage1 pressure injury include transparent dressings, hydrocolloid dressings, or no dressing and leaving the wound open to air. The wound should resolve without epidermal loss over a period of 7 to 14 days. Hydrogel dressings are used to maintain a moist environment for wound healing. Calcium alginate is absorbent and is used in stage 4 wounds or those with deeper tissue injury. Antimicrobial dressings are used for pressure injuries that are infected.
8. The nurse is preparing to give a full bed bath to a client. Which question is most important for the nurse to ask the client before beginning the bed bath? 1. "Do you have any allergies?" 2. "Will you be able to wash your own hair?" 3. "Are there any areas you want us to spend more time bathing?" 4. "Do you have any preferences regarding how we help you bathe?"
Answer: 1 Rationale: Bed baths involve applying water and a cleansing agent, such as soap or chlorhexidine gluconate (CHG), to the skin. The nurse needs to first inquire about any allergies to ensure that the client is not allergic to the cleansing agent that will be used. Although options 2, 3, and 4 are appropriate questions to ask the client, the determination of any client allergies is the most important client data to obtain before beginning the bed bath.
2. The nurse has given the client instructions about crutch safety. Which statements indicate that the client understands the instructions? Select all that apply. "I should not use someone else's crutches." "I need to remove any scatter rugs at home." "I can use crutch tips even when they are wet." "I need to have spare crutches and tips available." "When I'm using the crutches, my arms need to be completely straight."
Answer: 1, 2, 4 Rationale: The client should use only crutches measured for the client. When assessing for home safety, the nurse ensures that the client knows to remove any scatter rugs and does not walk on highly waxed floors. The tips need to be inspected for wear, and spare crutches and tips need to be available if needed. Crutch tips should remain dry. If crutch tips get wet, the client needs to dry them with a cloth or paper towel. When walking with crutches, both elbows need to be flexed not more than 30 degrees when the palms are on the handle.
