A client has urinary incontinence. Which assessment finding indicates that outcomes for a priority nursing diagnosis have been met?
The client reports drinking 8 to 9 glasses of water each day.
The client expresses satisfaction with undergarments for incontinence.
The family states that the client is more active and socializes more.
The skin in the perineal area is intact without redness upon inspection.
The Correct Answer is D
Choice A rationale:
While adequate hydration is important for overall health and urinary function, it does not directly address the priority nursing diagnosis of urinary incontinence. Increased fluid intake without addressing the underlying incontinence can actually exacerbate the problem by increasing urine output.
It's crucial to assess for signs of urinary retention or incomplete bladder emptying, as excessive fluid intake can worsen these conditions.
Individualized fluid intake goals should be established based on the client's overall health status, bladder capacity, and fluid balance.
Choice B rationale:
Satisfaction with incontinence products can improve comfort and quality of life, but it does not necessarily indicate that the underlying issue of incontinence has been resolved.
It's important to evaluate the effectiveness of incontinence products in managing leakage and preventing skin breakdown, but they should not be considered a definitive solution for incontinence.
Explore other interventions to address the root cause of incontinence, such as bladder training, pelvic floor muscle exercises, or medications.
Choice C rationale:
Increased activity and socialization can be positive outcomes of effective incontinence management, but they are not direct measures of the priority nursing diagnosis.
Improved social engagement and activity levels might reflect a reduction in incontinence episodes and increased confidence, but they should not be the sole indicators of success.
Assess for specific changes in incontinence frequency, severity, and impact on daily life to more accurately gauge progress.
Choice D rationale:
Intact, healthy skin in the perineal area is a direct and objective indicator that a priority nursing diagnosis of urinary incontinence has been met.
It demonstrates that the interventions implemented to manage incontinence have been effective in preventing skin breakdown and irritation, which are common complications of incontinence.
This finding aligns with the goal of maintaining skin integrity and preventing infection, which are essential aspects of incontinence care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Prednisone is a corticosteroid that suppresses the body's natural production of cortisol. Cortisol is a hormone that is essential for life, and it plays a role in many important bodily functions, including:
Regulating blood sugar levels Maintaining blood pressure Reducing inflammation Responding to stress
When a person takes prednisone for a long period of time, their body begins to rely on the medication to provide cortisol. If the medication is stopped suddenly, the body cannot produce enough cortisol on its own, which can lead to a life-threatening condition called adrenal insufficiency.
Adrenal insufficiency can cause a variety of symptoms, including: Extreme fatigue
Weakness Dizziness Nausea Vomiting Abdominal pain Confusion
Loss of consciousness
To prevent adrenal insufficiency, it is important to taper off prednisone slowly over a period of time. This allows the body to gradually adjust to producing cortisol on its own.
Here are some additional details about why prednisone should never be discontinued abruptly: The risk of adrenal insufficiency is highest when prednisone has been taken for more than 3 weeks. The longer a person has been taking prednisone, the slower the taper should be.
It is important to follow the tapering instructions provided by the healthcare provider.
If a person experiences any symptoms of adrenal insufficiency, they should seek medical attention immediately.
Correct Answer is D
Explanation
Choice A rationale:
Incorrect. Deep-breathing exercises could potentially worsen stridor. Stridor is a high-pitched, wheezing sound caused by a partial obstruction of the upper airway. Deep breathing can increase airflow through the narrowed airway, making the stridor more pronounced and potentially worsening the obstruction. In severe cases, it could lead to complete airway obstruction and respiratory distress.
Risk of aggravation: Deep-breathing exercises could aggravate the underlying cause of stridor, such as laryngeal edema or vocal cord dysfunction, by increasing inflammation or muscle tension in the airway.
Delay in definitive treatment: Focusing on deep-breathing exercises might delay more definitive interventions, such as intubation, which might be necessary to secure the airway and prevent respiratory failure.
Choice B rationale:
Incorrect. While albuterol nebulizer therapy can be helpful for bronchospasm, it is not the first-line treatment for stridor. Stridor is typically caused by an upper airway obstruction, and albuterol primarily targets the lower airways (bronchioles).
Limited effectiveness: Albuterol might not be effective in reducing stridor caused by upper airway obstruction, as it does not directly address the narrowing of the airway.
Potential for adverse effects: Albuterol can cause tachycardia, tremors, and anxiety, which could further complicate the patient's condition.
Choice C rationale:
Not the most immediate action. While calling a Rapid Response might be necessary if the patient's condition deteriorates, the first priority is to secure the airway and ensure adequate ventilation.
Time-consuming: Activating a Rapid Response team can take several minutes, and the patient's condition might not allow for that delay.
Choice D rationale:
Prioritizes airway management: Intubation is the most effective way to secure the airway and ensure adequate ventilation in a patient with stridor. It bypasses the obstruction and allows for controlled delivery of oxygen and ventilation.
Addresses potential for deterioration: Stridor can rapidly progress to complete airway obstruction, so prompt preparation for intubation is crucial to prevent respiratory failure.
Involves the primary healthcare provider: Consulting the primary health care provider ensures timely decision-making, appropriate medication administration (such as sedatives or paralytics for intubation), and coordination of care.
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