HESI Registered Nurse EXIT Practice Exam

Which of the following measures is most effective in preventing skin breakdown for a client with a CVA?

1. Place client in the wheelchair for four hours each day

2. Pad the bony prominence

3. Reposition every two hours

4. Massage reddened bony prominence

The correct answer is: Reposition every two hours

Repositioning a client every two hours is a highly effective measure in preventing skin breakdown, particularly for individuals with a cerebrovascular accident (CVA). This practice helps to alleviate pressure on specific areas of the body that are at risk for pressure ulcers, especially the bony prominences. By changing the position regularly, you reduce the sustained pressure that can restrict blood flow to the skin and underlying tissues, allowing for improved circulation and skin integrity. Maintaining regular movement also helps relieve moisture buildup, friction, and shear that can contribute to skin breakdown. In the case of clients with limited mobility, such as those recovering from a CVA, this proactive approach is critical for preserving skin health and preventing complications that ensue from prolonged pressure. Other measures, such as padding bony prominences, can be beneficial as adjuncts, but they are not sufficient on their own if the repositioning is neglected. Placing a client in a wheelchair for extended periods without proper repositioning can lead to increased risk of skin issues. Likewise, while massaging reddened areas may seem like a means of enhancing circulation, it can actually worsen skin integrity by increasing friction and irritation on compromised skin. Overall, regular repositioning is a cornerstone of effective skin care management in vulnerable patients