# A nurse is caring for a client with a spinal cord injury who has been immobile for 1 week. Which nursing intervention should be the priority to prevent complications related to immobility? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542661 > language: ko > subject: Fundamentals ## 문제 A nurse is caring for a client with a spinal cord injury who has been immobile for 1 week. Which nursing intervention should be the priority to prevent complications related to immobility? ## 보기 1. Encourage deep breathing exercises every 2 hours while awake 2. Apply sequential compression devices to lower extremities 3. Perform passive range of motion exercises to all joints twice daily 4. Reposition the client every 2 hours and assess skin integrity **✔ 정답** **정답: 4** ## 해설 Repositioning every 2 hours with skin assessment is the priority to prevent pressure ulcers, which develop rapidly in immobilized clients. Other interventions address different complications but are less immediate. ## 심화 해설 Understanding the Priority: Immobility and the Spinal Cord Injury Patient When a client with a spinal cord injury (SCI) is immobile for a week, the risk for complications escalates dramatically. While all the listed interventions are important, the nurse must prioritize based on the most immediate threat to physiological integrity. For an SCI patient, the loss of sensation and motor function below the level of injury creates a perfect storm for the development of pressure injuries (PIs). A systematic review and meta-analysis confirms that SCI predisposes patients to PIs, which are a serious and highly prevalent complication that can require surgery and significantly impact quality of life and rehabilitation [3,4]. Why Repositioning and Skin Assessment is the Priority The correct answer is to reposition the client every 2 hours and assess skin integrity. This intervention directly addresses the primary, evidence-based prevention strategy for pressure injuries. The foundational knowledge for this is that sustained pressure on bony prominences leads to tissue ischemia and necrosis, a process that begins within hours. A study on nurses' knowledge, attitude, and practice towards immobility complications highlights that high-quality preventive nursing care is achieved by nurses who are knowledgeable about the evidence-based strategies for preventing immobility-related complications [2]. Regular repositioning is the cornerstone of that preventive care, and for a patient who cannot feel or respond to the discomfort of prolonged pressure, it becomes a life-saving nursing action. The expert consensus further supports that a multidisciplinary approach, which includes vigilant skin assessment, is essential for PI prevention in this population [4]. Analyzing the Other Options The other options are not incorrect, but they address complications that are secondary in time-sensitivity compared to tissue breakdown. - Option 1: Encourage deep breathing exercises. This is crucial for preventing atelectasis and pneumonia, which are respiratory complications of immobility. However, the pathophysiological process of a pulmonary infection takes longer to develop than a pressure injury. Skin breakdown can begin after just two hours of unrelieved pressure, making its prevention a more urgent, time-dependent priority. - Option 2: Apply sequential compression devices (SCDs). SCDs are vital for preventing deep vein thrombosis (DVT), a significant risk in immobile patients. While a DVT can have a catastrophic acute event like a pulmonary embolism, the formation of the clot itself is a process that occurs over days. The immediate, localized tissue damage from pressure is a more pressing concern in the first week of immobility. - Option 3: Perform passive range of motion (PROM) exercises. PROM is essential to prevent contractures and muscle atrophy. While important for long-term rehabilitation and function, the development of a contracture is a subacute to chronic process. It does not pose the same immediate threat to skin and tissue integrity as unrelieved pressure does within a single shift. Connecting to Broader Safety Frameworks This prioritization aligns with the principles of patient-safety frameworks used in acute surgical care, which emphasize nursing-led safety behaviors to prevent immobility-related harms . The framework identifies early mobilization and the prevention of device-related injuries as core competencies. In the context of a newly injured SCI patient, "early mobilization" is operationalized through meticulous repositioning when the patient cannot move independently. The assessment of skin integrity is the direct surveillance component that allows the nurse to detect the earliest signs of pressure damage—non-blanchable erythema—before it progresses to a deeper, potentially surgical wound. This proactive surveillance and intervention are what differentiate high-quality, safe nursing care from reactive treatment of an already established complication [2,3].References (research sources) - [2]Nurses' knowledge, attitude, and practice towards immobility complications.Research articleAlhassoon AH, Alharazi R, Almutary H. (2026) · DOI: 10.1186/s12912-026-04700-1 - [4]The Correct Nutritional Intake in the Prevention and Treatment of Skin Lesions in Patients With Spinal Cord Injury.Research articleAreni A, Capeci W, Corsi A, Del Popolo G, De Palma L, Pelizzari L, Vercilli P. (2026) · DOI: 10.14740/jocmr6399 ## 임상 시나리오 Clinical Practice Guide: Preventing Pressure Injuries in Spinal Cord Injury Assessment and Repositioning Protocol For a client with a spinal cord injury who has been immobile for one week, the priority is to prevent pressure injuries through a systematic repositioning schedule. The standard of care is to reposition the client at least every 2 hours, using a written turning schedule to ensure consistency across all shifts. During each turn, perform a thorough skin assessment, paying close attention to all bony prominences such as the sacrum, heels, elbows, and occiput. Document skin condition meticulously using a validated tool like the Braden Scale. Key Points for Safe Repositioning - Use lift sheets or assistive devices to avoid dragging the client across the bed surface, which creates friction and shear forces that significantly increase injury risk. - Maintain proper spinal alignment at all times, using log-rolling techniques if the spinal injury is unstable or per surgeon's orders. - Utilize pressure-redistributing support surfaces, such as high-specification foam mattresses, as an adjunct to, not a replacement for, manual repositioning. - Inspect the skin under and around medical devices, such as cervical collars or braces, as these create additional pressure points. Interprofessional Collaboration Communicate any findings of non-blanchable erythema or skin breakdown immediately to the healthcare provider and wound care specialist. Integrate the repositioning plan into the overall rehabilitation goals, coordinating with physical and occupational therapy to ensure mobility exercises complement the pressure injury prevention strategy. ## 핵심 개념 - **Pressure Injury** — Localized damage to the skin and underlying soft tissue usually over a bony prominence, caused by intense and/or prolonged pressure in combination with shear. - **Tissue Ischemia** — A restriction in blood supply to tissues, causing a shortage of oxygen and glucose needed for cellular metabolism; in immobility, this is caused by unrelieved pressure. - **Bony Prominence** — Areas of the body where the bone is close to the skin surface, such as the sacrum, heels, and elbows, making them high-risk sites for pressure injuries. ## 같은 주제 문제 - [A nurse is assessing a patient's mobility status. Which assessment finding would be the mo…](https://mymerci.kr/pages/nclex_q.php?qn_id=542657) - [A nurse is assessing a patient who has been on bed rest for 5 days following abdominal sur…](https://mymerci.kr/pages/nclex_q.php?qn_id=542658) - [A nurse is caring for a client who has been on bed rest for 5 days following abdominal sur…](https://mymerci.kr/pages/nclex_q.php?qn_id=542659) - [A nurse is caring for a client with left-sided weakness following a stroke. Which position…](https://mymerci.kr/pages/nclex_q.php?qn_id=542660) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._