Author Question: The patient has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile ... (Read 46 times)

iveyjurea · **on:** Jul 22, 2018

The patient has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile because of arthritic discomfort. Which of the following interventions is the best one for this patient's skin integrity?

a. Having the patient sit up in a chair for four-hour intervals
b. Keeping the head of the bed in a high Fowler's position to increase circulation
c. Repositioning the patient at least every two hours
d. Encouraging the patient to perform pelvic muscle training exercises several times a day

Question 2

A patient's condition is slowly deteriorating. What actions should the nurse take to provide the best care possible? (Select all that apply.)

a. Allow the nursing student to receive verbal orders from the physician in the room while the nurse is in the medication area down the hall.
b. Document the patient's status changes in the medical record in a timely manner.
c. Document that the health care provider has been notified of the specific patient status, including date and time that messages were left.
d. Check the chart for frequent orders.
e. Omit charting what the health provider's response is to notification of the patient's status change.

phuda · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C

Feedback
A Patients able to sit in a chair should be limited to sitting for two hours or less.
B Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces.
C The frequency of repositioning should be individualized for the patient; however, patients should be repositioned at least every two hours.
D Pelvic muscle training may help prevent incontinence, but it is not the best intervention for maintaining the patient's skin integrity.

Answer to Question 2

B, C
Clear, concise, and timely communication is essential whenever charting in the patient's medical record occurs. Nursing students are not permitted to receive verbal orders. Documentation regarding communication with the health care provider must contain what was communicated by the nurse and the health care provider, orders if given, date, time, and identification of who is documenting the situation.