When assessing the skin of an immobilized patient, the nurse ...

[abarnes]

When assessing the skin of an immobilized patient, the nurse should
 
  a. Assess the skin at least every 4 hours.
  b. Use a standardized tool such as the Braden Scale.
  c. Use nursing instinct instead of a standardized tool.
  d. Have special times for inspection so as to not interrupt routine care.

Question 2

Communication skills are adapted for clients with special needs. How can the nurse enhance communication for a client with aphasia?
 
  a. Use visual cues
  b. Speak loudly
  c. Use open-ended questions
  d. Use a speech therapist to communicate with the client

[frejo]

Answer to Question 1

B
Consistently use a standardized tool, such as the Braden Scale. This identifies patients with high risk of impaired skin integrity. Nursing instinct in this case is not enough. At a minimum, skin assessment occurs every 2 hours. Continually assess the patient's skin for breakdown and color changes such as pallor or redness. Continual assessment reduces the need for the creation of special times for inspection.

Answer to Question 2

A
The nurse may enhance communication for a client with aphasia by using visual cues (e.g., words, pictures, and objects) when possible.
The nurse should not shout or speak too loudly to enhance communication with a person who has aphasia.
The nurse should ask simple questions that require yes or no answers to enhance communi-cation with the client who has aphasia.
Using a speech therapist is not the primary way to enhance communication with a client who has aphasia. The nurse can use communication techniques to facilitate communication and to develop a helping relationship with the client. The speech therapist may help the client to learn new communication methods or to relearn how to communicate.

[abarnes]

Excellent

[kishoreddi]

TYSM