A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should:
A. Turn him frequently.
B. Perform passive range-of-motion (ROM) exercises.
C. Reduce the client’s fluid intake.
D. Encourage the client to use a footboard.
Correct Answer: A. Turn him frequently.
The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn’t relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation.
Option B: During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn’t prevent pressure ulcers. ROM exercise helps in reducing muscle stiffness and spasticity. It can also help prevent contractures.
Option C: Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. Offer solid foods and liquids at different times. Prevents the patient from swallowing food before it is thoroughly chewed. In general, liquids should be offered only after the patient has finished eating foods.
Option D: A footboard prevents plantar flexion and foot drop by maintaining the foot in a dorsiflexed position. Discontinue use of footboard, when appropriate. Continued use (after a change from flaccid to spastic paralysis) can cause excessive pressure on the ball of the foot, enhance spasticity, and actually increase plantar flexion.
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