Following an automobile accident, a teenager is left paraplegic. ...

[Evvie72]

Following an automobile accident, a teenager is left paraplegic. The child is being prepared for discharge. The nurse is reviewing instructions to avoid decubitus ulcers on the buttocks and instructs the teenager to:
 
  1. Contract the buttock muscles five times every two hours.
  2. Increase fat in the diet to provide a protective coating over the boney prominences.
  3. Do wheelchair push-ups every 15 to 30 minutes.
  4. Avoid use of sheepskin as it prevents air from reaching the area.

Question 2

A 4-year-old has acute glomerulonephritis, and is admitted to the hospital. An appropriate nursing diagnosis for this child would be:
 
  1. Injury, risk for related to loss of blood in urine.
   2. Fluid Volume Excess related to decreased plasma filtration.
   3. Infection, risk for related to hypertension.
   4. Altered Growth and Development related to a chronic disease.

[honnalora]

Answer to Question 1

3
Rationale 1: The child is a paraplegic and therefore unable to contract the buttock muscles.
Rationale 2: Extra weight will add to pressure on the boney prominences and should be avoided.
Rationale 3: Lifting the buttocks with the arms can help with blood flow to the buttocks and reduce the risk of breakdown.
Rationale 4: Sheepskin can reduce pressure on the buttocks; it is one of many pressure reducing materials available.
Global Rationale:

Answer to Question 2

2
Rationale:
1. There is no risk for injury, because the blood loss in the urine is not sufficient to cause anemia.
2. The fluid is excessive, and fluid and electrolyte balance should be monitored.
3. While a risk for infection might be present, it is not related to the hypertension.
4. Growth and development are not normally affected, because this is an acute process, not a chronic one.

[Evvie72]

TYSM

[31809pancho]

Gracias!