Author Question: The nurse understands that a pressure ulcer is an impairment of the skin as a result of prolonged ... (Read 104 times)

evelyn o bentley · **on:** Jul 22, 2018

The nurse understands that a pressure ulcer is an impairment of the skin as a result of prolonged ischemia. What is one of the easiest ways to prevent a pressure ulcer from occurring in an im-mobile client?

a. Keep the skin dry.
b. Provide range-of-motion exercises every shift.
c. Use lift equipment when transferring a client.
d. Turn the client a minimum of every two hours.

Question 2

In which following instance does the nurse recognize that interventions for values clarification are beneficial for the client?

a. The client and nurse have different beliefs.
b. The client is experiencing a values conflict.
c. The nurse is unsure of the client's values.
d. The client has rejected normal values.

ciecieme · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D
Implementing a comprehensive skin care program can prevent skin breakdown in all clients, from neonates to older adults. Effective skin care programs include accurate and consistent assessment and documentation as well as interventions to protect the skin (e.g., turning the client at least every two hours).
Keeping the skin dry is very important in preventing skin breakdown, but turning the client will best help prevent pressure ulcers.
Range-of-motion exercises will help prevent contractures from occurring, but turning the client will best help prevent pressure ulcers.
Lift equipment will help decrease harm to both clients and staff, but turning the client will best help prevent pressure ulcers.

Answer to Question 2

B
Values clarification is the process of appraising one's own personal values. It is not a set of rules; nor does it suggest that certain values should be accepted by all people.
Values clarification can help nurses strengthen their ability to advocate for clients, as nurses are better able to accurately identify the personal values of clients. Values clarification is not neces-sarily beneficial to the client when the client and nurse have differing beliefs.
Values clarification will not necessarily help the nurse who is unsure of the client's values. Values clarification interventions are for the benefit of the client and not for the nurse to gain awareness.
The values that an individual holds reflect cultural and social influences, relationships, and per-sonal needs. Values vary among people and develop and change over time. Therefore, it may be inappropriate to state that a client has rejected normal values when different value systems ex-ist among people. What is considered normal for one person may not be so for another.