# A client has limited mobility after a stroke and is at high risk for pressure injury. For each group, select all responses that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=620052&lang=en  
> language: en  
> subject: Personal Hygiene  
> category: BCC

## Question

A client has limited mobility after a stroke and is at high risk for pressure injury. For each group, select all responses that apply.

Skin care

Inspect skin over bony prominences each day and with care

Use hot water and strong soap for daily bathing

Apply moisturizer to dry intact skin

Massage persistent nonblanchable redness

Positioning and movement

Reposition on an individualized schedule based on risk and tissue tolerance

Use a donut-shaped cushion under the sacrum

Keep the head of bed above 60 degrees continuously without another indication

Use a lift sheet or assistive device to reduce friction and shear

## Explanation

Inspect vulnerable skin and moisturize dry skin while avoiding hot water and massage of nonblanchable redness. Repositioning should follow an individualized schedule based on risk and tissue tolerance, and a lift sheet reduces friction and shear. Donut cushions concentrate pressure, and continuously keeping the head of bed above 60 degrees increases sacral shear unless another clinical need requires that position.

## In-depth explanation

Quick answer
Inspect vulnerable skin and moisturize dry skin while avoiding hot water and massage of nonblanchable redness. Repositioning should follow an individualized schedule based on risk and tissue tolerance, and a lift sheet reduces friction and shear. Donut cushions concentrate pressure, and continuously keeping the head of bed above 60 degrees increases sacral shear unless another clinical need requires that position.
Key cues
Use only the findings, timing, and orders stated in the scenario.
Clinical reasoning
Apply the requested nursing decision to this client rather than relying on a broad disease label.
Why the alternatives do not fit
The remaining responses are contradicted by the scenario, mistimed, outside scope, or unsafe.
Priority and safety
Address immediate threats first and reassess after intervention.
Takeaway
Choose only actions supported at this exact point in care.
**Sources**
- Open RN Nursing Skills 2e

## Clinical scenario

A client has limited mobility after a stroke and is at high risk for pressure injury. For each group, select all responses that apply.

## Key concepts

- **pressure injury** — pressure injury is a key clinical concept for assessing and managing pressure-injury prevention.
- **repositioning** — repositioning is a key clinical concept for assessing and managing pressure-injury prevention.
- **shear** — shear is a key clinical concept for assessing and managing pressure-injury prevention.

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