Multidimensional Care I (Rasmussen College) (MDC1)

The correct answers are:

A. Cleansing the skin routinely after soiling occurs

B. Applying moisturizer to dry areas of skin

C. Using a Hoyer lift for all transfers.

Explanation of Correct Answers:

A. Cleansing the skin routinely after soiling occurs.

Keeping the skin clean and dry is essential in preventing pressure injuries. Excess moisture from incontinence, sweat, or wounds weakens the skin's protective barrier, making it more prone to breakdown. Routine cleansing after soiling prevents irritation and reduces the risk of infection.

B. Applying moisturizer to dry areas of skin.

Dry, fragile skin is more susceptible to cracking and pressure injuries. Using fragrance-free moisturizers helps maintain skin integrity and elasticity, preventing damage from friction and shear forces.

C. Using a Hoyer lift for all transfers.

Manual repositioning can cause shear and friction forces, which contribute to skin breakdown and pressure injury development. A Hoyer lift minimizes skin trauma and prevents unnecessary pressure on bony prominences, especially in a frail, malnourished client with reduced muscle mass and fat padding.

Explanation of Incorrect Answers:

D. Massaging the client’s reddened shoulders and heels.

Massaging areas of redness (stage 1 pressure injuries) can worsen tissue damage by increasing pressure, damaging fragile capillaries, and leading to ulcer progression. Instead, the nurse should relieve pressure on reddened areas by repositioning the client and using pressure-relieving surfaces.

E. Reposition client once per shift.

Repositioning only once per shift (typically every 8–12 hours) is not frequent enough to prevent pressure injuries in high-risk clients. The recommended standard of care is repositioning every 2 hours for bedridden clients to offload pressure from bony prominences and improve circulation.

Summary:

To prevent pressure injuries in a frail, bedridden client, the nurse should cleanse the skin routinely after soiling, apply moisturizers to dry areas, and use a Hoyer lift for safe transfers. The nurse should not massage reddened areas and should reposition the client every 2 hours rather than just once per shift.

The correct answer is: D. Cleanse the client's face

Explanation:

When providing a routine bed bath, the nurse should follow the proper sequence to maintain hygiene and prevent the spread of bacteria. The face is cleansed first because it is one of the cleanest areas of the body, and cleaning it before other areas prevents contamination. The perineal area and feet are cleaned last because they are more likely to harbor bacteria.

Why This Answer Is Correct:

D. Cleanse the client's face 

The face is one of the least contaminated areas and should be washed first. This helps prevent the spread of bacteria to cleaner areas. The eyes should be wiped from the inner to the outer corner with a clean part of the washcloth to prevent infection.

Why the Other Options Are Incorrect:

A. Cleanse the client's hands 

The hands are not the first area to be cleaned because the face should be prioritized to prevent contamination. The hands can contain germs, so they are usually cleaned after the face and upper body.

B. Cleanse the client's feet 

The feet are one of the dirtiest areas of the body and should be washed near the end of the bath to avoid spreading bacteria. Washing the feet first could transfer germs to cleaner areas like the face and upper body.

C. Cleanse the client's perineal area 

The perineal area is highly contaminated and should be washed last to prevent spreading bacteria to other parts of the body. Washing this area first could lead to cross-contamination, increasing the risk of infection.

Summary:

When giving a routine bed bath, the face should be washed first because it is the cleanest area. The perineal area and feet should be washed last to prevent contamination. Following a proper cleansing sequence ensures hygiene, comfort, and infection prevention.

The correct answer is: A. Alcohol.

Explanation:

Gout is an inflammatory arthritis caused by excess uric acid in the bloodstream, leading to crystal formation in the joints. Alcohol, particularly beer and liquor, is a known trigger for gout attacks because it increases uric acid production and decreases renal excretion. Additionally, alcohol contributes to dehydration, which further promotes crystal formation in the joints, leading to pain and inflammation.

Why the Other Options Are Incorrect:

B. Fruit juice

While some fruit juices, especially those high in fructose (such as apple or orange juice), may contribute to uric acid levels, they are not as potent as alcohol in triggering gout attacks. However, moderation is advised.

C. Milk

Low-fat dairy products, including milk, have been shown to lower uric acid levels and may actually help reduce the risk of gout attacks. They promote uric acid excretion through the kidneys and have protective properties.

D. Coffee

 Some studies suggest that coffee may lower uric acid levels by increasing its excretion. Coffee consumption is not a known trigger for gout and may even have protective effects.

Summary:

Alcohol is the most significant beverage-related trigger for gout attacks due to its impact on uric acid metabolism and kidney excretion. While fruit juices should be consumed in moderation due to fructose content, milk and coffee do not contribute to gout flare-ups and may even be beneficial.

The correct answer is: D. Inform the client that driving would be dangerous.

Explanation of Correct Answer:

Narcolepsy is a chronic neurological disorder that affects the brain's ability to regulate sleep-wake cycles. Clients with narcolepsy experience sudden, uncontrollable episodes of sleep, which can be dangerous, especially when performing activities that require full alertness, such as driving. The priority intervention is to educate the client about the dangers of driving, as falling asleep behind the wheel can result in serious or fatal accidents. Clients should avoid driving unless their condition is well-managed with medication and behavioral strategies.

Explanation of Incorrect Answers:

A. Encourage the client to stop drinking caffeine after 6 pm

While managing caffeine intake can help regulate sleep patterns, it is not the priority intervention. Caffeine can help maintain alertness during the day, but stopping caffeine in the evening mainly helps improve nighttime sleep rather than addressing the immediate safety risk posed by narcolepsy-related sleep attacks.

B. Inform the client to drink two cups of regular coffee

While caffeine can help promote wakefulness, it is not a reliable treatment for narcolepsy. Narcolepsy is caused by a dysfunction in the brain’s regulation of sleep, and relying on coffee is not a safe or effective solution. Medications such as modafinil or stimulants are typically prescribed for narcolepsy under a healthcare provider’s guidance. More importantly, caffeine does not prevent sudden sleep attacks, making safety precautions like avoiding driving a higher priority.

C. Encourage the client to participate in normal activities

Encouraging normal activities is beneficial for mental and social well-being, but it does not directly address the priority safety concern. Clients with narcolepsy should engage in normal activities but must modify certain high-risk tasks (such as driving or operating heavy machinery) to prevent accidents.

Summary:

The priority intervention for a client with narcolepsy is to inform them that driving is dangerous due to the risk of sudden sleep attacks. While managing caffeine intake and encouraging normal activities are helpful, they do not directly address the immediate safety concerns. Drinking coffee is not a sufficient solution to prevent sleep attacks. Therefore, avoiding dangerous activities like driving is the most critical nursing intervention.

The correct answer is: B. Check medication administration record (MAR) for as-needed orders (PRN)

Explanation:

Pain management is the priority before performing a painful procedure such as a dressing change. The client has reported that their pain increases from 5/10 to 10/10 during dressing changes, which indicates that pain control should be addressed before proceeding. Checking the MAR for PRN pain medication orders ensures that the nurse can administer analgesia before the dressing change, helping to minimize pain and distress. Best practice guidelines recommend premedicating clients 30-60 minutes before a painful procedure such as a dressing change to improve comfort and compliance with wound care.

Why the other choices are incorrect:

A. Remove the old dressing with clean gloves

This is incorrect because starting the dressing change without addressing the client’s pain will cause unnecessary suffering. Pain management should be provided first to ensure the client is comfortable.

C. Teach the client about nonpharmacological pain control methods

This is incorrect because while nonpharmacological techniques (such as guided imagery, deep breathing, and distraction) can be helpful, they should be used as a supplement to pain medication, not as the primary method for managing severe pain. Addressing pain with medication first is the priority.

D. Offer the client protein with meals to promote healing

This is incorrect because while nutrition plays a role in wound healing, it does not address the immediate issue of pain relief before a dressing change. Ensuring adequate protein intake is important for long-term healing but is not the priority intervention in this scenario.

Summary:

The priority action is to check the MAR for PRN pain medication orders and administer analgesia before proceeding with the dressing change. This ensures that the client’s pain is managed effectively, preventing unnecessary discomfort. While nonpharmacological pain methods and proper nutrition are important, they do not replace the need for pain medication before a painful procedure.

The correct answer is: A. The client with AIDS is a susceptible host.

Explanation:

Clients with acquired immunodeficiency syndrome (AIDS) have a weakened immune system due to the destruction of CD4 (T-helper) cells by the human immunodeficiency virus (HIV). This makes them more vulnerable to opportunistic infections, such as pneumonia, tuberculosis, and fungal infections, which a healthy individual with an intact immune system can typically fight off. Opportunistic infections occur when the immune system is compromised, meaning the client with AIDS becomes a "susceptible host"—one of the key components in the chain of infection.

Why the Other Options Are Incorrect:

B. The client with AIDS was not as careful

While infection prevention measures (such as hand hygiene and avoiding sick contacts) are important, the primary reason the client with AIDS develops pneumonia is due to a weakened immune system, not simply a lack of caution. Even with strict precautions, they remain highly vulnerable to infections.

C. The client with AIDS has more portals of entry 

A portal of entry refers to the route through which a pathogen enters the body (e.g., respiratory tract, broken skin, mucous membranes). Having AIDS does not increase the number of portals of entry; rather, it weakens the body's ability to fight infections that enter through normal routes.

D. The client with AIDS has greater immune defenses

This statement is the opposite of the truth. AIDS is characterized by a significant loss of immune defenses, making the client more prone to infections. A healthy individual has a fully functioning immune system that can recognize and destroy pathogens before they cause illness.

Summary:

A client with AIDS is more likely to develop pneumonia than a healthy individual because they are a susceptible host due to severe immune suppression. The loss of CD4 cells makes it difficult for their body to mount a defense against pathogens, leading to a higher risk of serious infections that a healthy person can usually fight off.

The correct answer is: A. Client will remain free from falls throughout their hospital stay.

Explanation

A. Client will remain free from falls throughout their hospital stay.

For an elderly client after hip surgery, the primary concern is preventing injury, particularly falls. A fall could cause serious complications such as dislocation, fractures, or delayed healing. This goal is specific, measurable, and realistic for the duration of the hospital stay. Since the client is at risk for injury, the most appropriate goal is to focus on safety and fall prevention.

Explanation of Incorrect Answers:

B. Client will increase activity tolerance by discharge from the hospital.

While increasing activity tolerance is important, it is not the primary concern immediately after hip surgery. The main focus should be fall prevention and safety. Activity tolerance may improve gradually, but the risk of falls remains the priority.

C. Client will demonstrate effective breathing pattern when ambulating throughout hospital stay.

Breathing patterns are not the primary concern for a client after hip surgery unless they have a respiratory condition. While proper breathing is important for mobility and oxygenation, the main risk for this client is fall-related injury.

D. Client will increase mobility by the time of discharge from the hospital.

While mobility is a key aspect of recovery, the priority is ensuring safety. The client’s mobility may increase gradually with physical therapy, but preventing injury takes precedence over mobility improvement.

Summary:

The most appropriate goal for an elderly client after hip surgery is to prevent falls and injury. While increasing mobility and activity tolerance are important aspects of recovery, they are not as critical as ensuring the client remains free from falls during their hospital stay.

The correct answer is: B. Stage 2.

Explanation

A Stage 2 pressure ulcer is characterized by:

Partial-thickness skin loss involving the epidermis and dermis.

The wound is shallow and open with a red or pink wound bed.

Slough may be present, but there is no exposure of fat, muscle, tendon, or bone.

Since the nurse described a shallow, open, reddened ulcer with slough on the right heel, this matches the Stage 2 description, as Stage 2 ulcers are superficial wounds with partial-thickness tissue loss.

Explanation of Incorrect Answers:

A. Stage 1

A Stage 1 ulcer presents as non-blanchable redness on intact skin. There is no open wound or slough in Stage 1. Since this wound is open, it cannot be Stage 1.

C. Stage 3

A Stage 3 ulcer involves full-thickness skin loss, where subcutaneous fat may be visible. Slough may be present, but the wound is deeper than a Stage 2 ulcer. Since this wound is shallow, it does not meet the criteria for Stage 3.

D. Stage 4

A Stage 4 ulcer has full-thickness skin and tissue loss with exposed bone, muscle, or tendon. Slough and eschar may be present, but deep structures must be visible. This wound description does not mention bone, muscle, or tendon exposure, so it is not Stage 4.

Summary:

Since the ulcer is shallow, open, reddened, and has slough but no visible fat, muscle, or bone, it is classified as Stage 2. Stage 1 ulcers are intact, while Stage 3 and 4 ulcers involve deeper tissue damage. The correct answer is B. Stage 2.

The correct answer is: D. Use a mechanical lift to reposition the client every 2 hours.

Explanation:

Friction and shear injuries occur when the skin is dragged across a surface, causing damage to the underlying tissue. This is a major concern in geriatric, immobile, and sedated clients, especially those who are intubated, as they cannot reposition themselves. Using a mechanical lift helps reduce friction and shear by lifting rather than dragging the client. It ensures safe repositioning without excessive pressure on the skin, reducing the risk of pressure injuries (bedsores). Repositioning every 2 hours is a standard nursing intervention to prevent skin breakdown.

Why the other choices are incorrect:

A. Postpone daily bed bath

This is incorrect because daily hygiene is important for infection prevention, skin integrity, and overall comfort. While excessive bathing can dry out the skin, proper skin care with moisturizers helps prevent skin breakdown. The key to reducing shear and friction is safe repositioning, not avoiding hygiene care.

B. Elevate the client’s head of the bed to 45 degrees

This is incorrect because elevating the head of the bed above 30 degrees increases shear forces. When the bed is elevated too high, the client’s body slides downward, causing the skin and deeper tissues to move at different rates, increasing the risk of skin damage. The head of the bed should be kept at 30 degrees or lower unless contraindicated (e.g., risk for aspiration).

C. Caregiver independently slides the client up in bed

This is incorrect because sliding a client up in bed without using proper techniques (e.g., lift sheet, draw sheet, or mechanical lift) creates significant shear forces. This can tear fragile skin, leading to pressure injuries. Instead, a two-person assist with a lift sheet or mechanical lift should be used.

Summary:

To minimize friction and shear injury, a mechanical lift should be used to reposition the client every 2 hours. This prevents dragging of the skin and reduces pressure injury risk. Proper positioning techniques, including keeping the head of the bed at 30 degrees or lower when possible, using lift sheets, and ensuring regular skin care, are essential in preventing skin breakdown in geriatric and immobile clients.