Author Question: To reduce pressure points that may lead to pressure ulcers, the nurse should: 1. Position the ... (Read 135 times)

cherise1989 · **on:** Jul 23, 2018

To reduce pressure points that may lead to pressure ulcers, the nurse should:

1. Position the client directly on the trochanter when side-lying
2. Use a donut device for the client when sitting up
3. Elevate the head of the bed as little as possible
4. Massage over the bony prominences

Question 2

In reviewing the client's nutritional intake, the nurse wants to recommend intake of foods that will specifically promote collagen synthesis and capillary wall integrity. The nurse suggests that the client eat:

1. Fish
2. Eggs
3. Liver
4. Citrus fruits

Tonyam972 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 3
Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer de-velopment from shearing forces. The client should not be positioned directly on the trochanter because this can create pressure over the bony prominence. Donut-shaped cushions are contrain-dicated because they reduce blood supply to the area, resulting in wider areas of ischemia. Bony prominences should not be massaged. Massaging reddened areas increases breaks in the capillar-ies in the underlying tissues and increases the risk for injury to underlying tissue and pressure ul-cer formation.

Answer to Question 2

ANS: 4
Citrus fruits contain vitamin C, which is important in collagen synthesis, capillary wall integrity, and fibroblast function. Fish and eggs contain protein and vitamin E. Protein plays a role in neo-genesis, collagen formation, and wound remodeling. Liver contains vitamin A, which is im-portant in epithelialization and wound closure.