Which of the following nursing documentation best reflects the ...

[jwb375]

Which of the following nursing documentation best reflects the observable assessment of skin breakdown on the heel of an African American client?
 
  1. 2-cm area of scaly, dry skin located on the client's right heel.
  2. 2-cm area of nonblanching erythema located on the client's right heel.
  3. 2-cm area purplish blue in color surrounded by lighter-colored skin located on right heel.
  4. 2-cm area of blanching erythema located on the client's right heel; entire foot warm to the touch.

Question 2

Which of the following interventions is mostly likely to minimize the cause of a pressure ulcer on the left buttock of a client who is comatose?
 
  1. Turn and position the client at least every 2 hours.
  2. Use a lift sheet when moving the client up in the bed.
  3. Change wet, soiled clothing as promptly as it is detected.
  4. Keep the head of the client's bed elevated to less than 30 degrees.

[macmac]

Answer to Question 1

ANS: 3
In dark-skinned individuals areas of pressure appear darker than surrounding skin and have a purplish/bluish hue; the temperature of the area may be warm or cool to the touch. The remaining options use descriptives not applicable to the dark-skinned individual or less definite indicators.

Answer to Question 2

ANS: 1
Pressure is the major cause in pressure ulcer formation, and changing the client's position to minimize the time spent in a particular position will be the best intervention to relieve the pres-sure.