When planning care for a client at risk for the development of ...

[cnetterville]

When planning care for a client at risk for the development of pressure ulcers, which of the following should be included in the care?
 
  1. Turn the client every 4 hours.
   2. Massage pressure areas with lotion every 4 hours.
   3. Use inflatable doughnut-style devices to reduce pressure on the sacrum.
   4. Initiate a frequent toileting schedule.

Question 2

The nurse learns that when a 75-year-old client bends forward to test flexion of the spine, the client is unable to touch the toes and has difficulty straightening after the test.
 
  Which of the following would explain these findings in this client? 1. The client has a herniated disk.
   2. The client has a fractured hip.
   3. Degeneration of the vertebral joints has caused thickening of the synovial fluid.
   4. Muscle fibers decrease as a normal part of the aging process.

[yotaSR5]

Answer to Question 1

4. Initiate a frequent toileting schedule.

Rationale:
Urine and feces are destructive to skin. A frequent toileting schedule will reduce periods of incontinence and potential for skin breakdown. The client should be turned at least every 2 hours. Massage of pressure areas can cause friction and damage to problem skin areas. Inflatable doughnut-style devices rings are contraindicated, as they increase pressure and reduce perfusion to affected areas.

Answer to Question 2

3. Degeneration of the vertebral joint has caused thickening of the synovial fluid.

Rationale:
Bending over to touch the toes is a test of spine flexion. The elderly client's inability to touch the toes could be due to degeneration of the vertebral joints, which causes thickening and decreased viscosity of the synovial fluid. The client would exhibit a list in the presence of a herniated disk. There is no evidence to suggest the client has a fractured hip. Muscle fibers do decrease as a normal part of the aging process but would not explain why the client is unable to toes the toes.

[cnetterville]

TYSM

[cassie_ragen]

Gracias!