The nurse is providing care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the care plan to help prevent the development of pressure Injuries?
Reposition the client at least every two hours.
Encourage the client to limit fluid intake.
Use a donut-shaped cushion under the client's hips.
Apply a heating pad to the client's back every four hours
The Correct Answer is A
A. Reposition the client at least every two hours. Regular repositioning reduces prolonged pressure on specific areas of the body, which helps prevent the formation of pressure injuries.
B. Encourage the client to limit fluid intake. Adequate hydration is important for skin integrity. Limiting fluid intake could lead to dehydration, increasing the risk for skin breakdown.
C. Use a donut-shaped cushion under the client's hips. Donut-shaped cushions can actually increase pressure around the edges of the cushion and restrict blood flow, which could worsen pressure injury risk.
D. Apply a heating pad to the client's back every four hours. Heat can cause skin damage and may increase the risk of burns. Temperature regulation is important, but heating pads are not recommended for pressure injury prevention.
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Correct Answer is ["B","C","D"]
Explanation
A. Obese extremities. Clients with Cushing's syndrome typically experience central (truncal) obesity with thin extremities due to fat redistribution and muscle wasting, not obese extremities.
B. Buffalo hump: A "buffalo hump" (fat pad on the back of the neck) is a common characteristic of Cushing's syndrome due to abnormal fat distribution.
C. Purple striations. Purple or reddish striae on the abdomen and other areas are commonly seen in Cushing's syndrome due to skin thinning and collagen breakdown.
D. Moon face. A round, full face (moon face) is a classic sign of Cushing's syndrome due to fat deposits in the face.
E. Tremors. Tremors are not typically associated with Cushing's syndrome and are more often associated with neurological or metabolic conditions.
Correct Answer is D
Explanation
A. Asthma: Asthma is a respiratory condition and is not a common complication associated with diabetes.
B. Osteoporosis: Osteoporosis is a bone disease more commonly associated with hormonal changes, aging, or steroid use, not directly linked to diabetes.
C. Liver cirrhosis: Liver cirrhosis is usually caused by alcohol use, hepatitis, or other liver diseases, not directly due to diabetes.
D. Cardiovascular disease: Diabetes is a significant risk factor for cardiovascular disease due to its association with atherosclerosis, hypertension, and dyslipidemia.