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 D
Explanation
A. Hypotension: Patients with SIADH typically have fluid retention, which can lead to hypertension, not hypotension.
B. Dry mucous membranes: In SIADH, fluid retention is common, so mucous membranes are usually moist, not dry.
C. Increased thirst: While thirst can occur in various conditions, it is not a primary symptom of SIADH.
D. Confusion or altered mental status: Confusion or altered mental status may occur in SIADH due to hyponatremia from excessive water retention.
Correct Answer is C
Explanation
A. Influenza: Influenza typically presents with a high fever, muscle aches, and fatigue, which are not present in this case.
B. Strep Throat: Strep throat usually presents with a sore throat, high fever, and swollen lymph nodes, not nasal congestion or watery eyes.
C. Rhinitis: Rhinitis, particularly allergic rhinitis, causes symptoms such as sneezing, nasal congestion, watery eyes, and malaise without fever, making it the most likely diagnosis.
D. Bacterial Pharyngitis: Bacterial pharyngitis often presents with a sore throat, fever, and swollen lymph nodes, but typically does not include nasal congestion or watery eyes.