Answer to Question 1
C
The frequency of repositioning should be individualized for the client; however, clients should be repositioned at least every two hours. The Registered Nurses Associated of Ontario (RNAO) recommends that a written turning and positioning schedule be used.
Clients able to sit in a chair should be limited to sitting for two hours or less.
Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer de-velopment from shearing forces.
Pelvic muscle training may help prevent incontinence, but it is not the best intervention for maintaining the client's skin integrity.
Answer to Question 2
C
The first step in processing an ethical dilemma is determining whether the problem is an ethical one. The nurse who cannot figure out what is right is stating a characteristic of an ethical dilem-ma, which is that the problem is perplexing. The next step is to gather as much relevant infor-mation as possible.
The nurse who wants to know the legalities of the living will of a client is collecting some, but not all, data pertaining to the problem.
The statement My spiritual beliefs mandate that I continue to provide all the interventions within my scope of practice. describes the nurse's own beliefs.
The nurse is describing the problem in terms of her feelings.
A client is having an endoscopy performed by a physician who views the upper gastrointestinal intern
Assessment for skin turgor
Common skin signs are often evidence of an illness or disorder. A wheal is a localized, evanescent ...
Structure of the skin.
Skin lesions.