Author Question: The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up ... (Read 47 times)

jrubin · **on:** Jul 22, 2018

The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair?

a. At least 3 hours
b. Not longer than 30 minutes
c. Less than 2 hours
d. As long as the patient remains comfortable

Question 2

After visiting with a client, the nurse documents the assessment data. Both objective and subjective information have been obtained during the assessment. Which of the following is classified as objective data?

a. Pain in the left leg
b. Elevated BP
c. Fear of surgery
d. Discomfort with breathing

ong527 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C
When patients are able to sit up in a chair, make sure to limit the amount of time to 2 hours or less. The chair sitting time should be individualized. In the sitting position, pressure on the ischial tuberosities is greater than in a supine position. Utilize foam, gel, or an air cushion to distribute weight. Longer than 2 hours can increase the chance of ischemia.

Answer to Question 2

B

Feedback
A Subjective data are clients' perceptions about their health problems, such as pain.
B Objective data are observations or measurements made by the data collector, such as a BP reading.
C Fear of surgery would be subjective data because it is the client's perception and not something the data collector can measure.
D Subjective data are clients' perceptions about their health problems, such as discomfort with breathing. A respiratory rate measurement would be an example of objective data.