An older adult client with friable skin and poor skin turgor has slipped down in the bed.Which action by the nurse is appropriate to safely reposition this client to prevent further skin breakdown?

Question

Quizplus · Accepted Answer

A) The client is malnourished and has friable skin, which increases the potential for shearing forces. Shearing forces lead to skin breakdown and pressure ulcers. To prevent shearing of the client's skin, the nurse should lift the client up in bed, using the client's legs and arms for assistance. Pulling the client will cause skin shearing. Sliding on a bed sheet also has the potential to cause shearing because the skin may adhere to the sheet. Placing the bed in reverse Trendelenburg will not facilitate the appropriate adjustment of the client in the bed.
B) The client is malnourished and has friable skin, which increases the potential for shearing forces. Shearing forces lead to skin breakdown and pressure ulcers. To prevent shearing of the client's skin, the nurse should lift the client up in bed, using the client's legs and arms for assistance. Pulling the client will cause skin shearing. Sliding on a bed sheet also has the potential to cause shearing because the skin may adhere to the sheet. Placing the bed in reverse Trendelenburg will not facilitate the appropriate adjustment of the client in the bed.
C) The client is malnourished and has friable skin, which increases the potential for shearing forces. Shearing forces lead to skin breakdown and pressure ulcers. To prevent shearing of the client's skin, the nurse should lift the client up in bed, using the client's legs and arms for assistance. Pulling the client will cause skin shearing. Sliding on a bed sheet also has the potential to cause shearing because the skin may adhere to the sheet. Placing the bed in reverse Trendelenburg will not facilitate the appropriate adjustment of the client in the bed.
D) The client is malnourished and has friable skin, which increases the potential for shearing forces. Shearing forces lead to skin breakdown and pressure ulcers. To prevent shearing of the client's skin, the nurse should lift the client up in bed, using the client's legs and arms for assistance. Pulling the client will cause skin shearing. Sliding on a bed sheet also has the potential to cause shearing because the skin may adhere to the sheet. Placing the bed in reverse Trendelenburg will not facilitate the appropriate adjustment of the client in the bed.

An Older Adult Client with Friable Skin and Poor Skin