A Nurse Is Working with a Client Who Has a Diagnosis

question 23

Multiple Choice

A nurse is working with a client who has a diagnosis of "Impaired skin integrity, related to immobility, secondary to neurologic dysfunction". Of the following listed, which would be considered an observation intervention?

• A) Provide ongoing assessment for skin breakdown during every shift.
• B) Cushion bony prominences with soft foam while in bed.
• C) Turn and reposition client every two hours.
• D) Apply lotion to dry skin twice daily.

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Definitions:

Diffusing

The process of a substance spreading from an area of high concentration to an area of lower concentration.

Respiratory Passageways

The paths that air follows to enter and exit the lungs, including the nose, throat, trachea, and bronchi.

Epiglottis

Tissue flap that folds down to prevent food from entering the trachea during swallowing.

Glottis

Opening formed when the vocal cords relax.