High School

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

A. Place the client in high-Fowler's position
B. Increase the client's intake of carbohydrates
C. Massage reddened areas with unscented lotion
D. Have the client use a trapeze bar when changing positions

Answer :

Final answer:

To prevent skin breakdown in a client with limited lower extremity mobility, the nurse should encourage the use of a trapeze bar for changing positions. This reduces continuous pressure on particular skin areas, which can lead to skin breakdown. Other listed measures are ineffective or can cause more harm to the skin.

Explanation:

In caring for a client who has limited mobility in his lower extremities, the nurse needs to consider strategies for preventing skin breakdown, which is a common issue in such cases. Among the options provided, having the client use a trapeze bar when changing positions is the most suitable. This tool will allow the client to shift their weight and change their position more frequently, reducing constant pressure on specific areas of the skin, which can lead to skin breakdown. The use of a high-Fowler's position or increasing carbohydrates intake does not relate directly to skin integrity. Massaging reddened areas is not recommended as it can lead to further damage to the skin.

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Final answer:

To prevent skin breakdown, the nurse should have the client use a trapeze bar when changing positions, which will help shift the body weight, reducing pressure on specific areas. Other interventions could include regular skin checks, maintaining skin cleanliness, and use of pressure-reducing devices.

Explanation:

In order to prevent skin breakdown in a client who has limited mobility in his lower extremities, the nurse should aim at eliminating pressure from the vulnerable areas. In this case, utilizing a

trapeze bar

for changing positions can be very beneficial as it provides the client with an ability to shift and adjust his body weight, reducing constant pressure on any particular body part. Massage, while can increase circulation, could potentially cause harm if done on reddened areas that are showing signs of potential skin breakdown. Therefore, massaging such areas with unscented lotion might not be advised. Similarly, while diet is crucial for overall health, an increase in carbohydrate intake won’t specifically prevent skin breakdown. Lastly, High-Fowler's position is more for respiratory comfort and may not address skin integrity. In addition to these, regular skin checks, maintaining skin cleanliness and dryness, and use of pressure-reducing devices like special mattresses or cushions can also be done to prevent skin issues like

decubitus ulcers or bedsores

.

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