A client who is recently diagnosed with stage IV ovarian cancer tells the practical nurse (PN) that the staff on the unit are insensitive and begins to cry. Which intervention(s) should the PN implement? Select all that apply.

A. Alteration in comfort: Restlessness, shallow breathing, and clenching teeth are strong indicators of discomfort or pain, especially in a client with aphasia who cannot verbalize needs. Assessing for pain or other sources of distress is the priority to address the client’s immediate comfort and prevent further deterioration.
B. Deficit in diversional activity: While limited activity can impact emotional health, signs like restlessness and physical tension suggest an immediate physical problem rather than boredom or inactivity. Comfort issues must be addressed first before considering diversional needs.
C. Elevated blood pressure: Stroke patients are at risk for hypertension, but restlessness and shallow respirations alone do not directly indicate elevated blood pressure. Blood pressure may rise secondary to pain or distress, but comfort assessment is still the initial focus.
D. Change in blood glucose level: Blood glucose fluctuations can cause changes in mental status or energy levels, but the client’s symptoms of clenching teeth and shallow breathing more strongly point toward discomfort or pain rather than hypoglycemia or hyperglycemia.

• Overflow urinary incontinence: Overflow incontinence occurs when the bladder becomes overly full and urine leaks out because it cannot empty properly. The client’s limited communication ability, along with wet clothes and sheets despite voiding only 75 mL of urine, suggests that the bladder is not emptying fully. This is consistent with overflow incontinence, which is often seen in individuals with neurological impairments like cerebral palsy, where bladder control is compromised.
• Urge incontinence: Urge incontinence occurs when the client has a sudden, intense urge to void, followed by involuntary leakage before reaching the bathroom. The client’s symptoms, including wet clothing and a small volume of urine, do not suggest an overwhelming urge to urinate. Given the client’s cognitive and communicative impairments, urge incontinence is less likely than overflow incontinence, which fits better with the clinical presentation.
• Reflex urinary incontinence: Reflex urinary incontinence occurs due to a loss of voluntary control over bladder function, often following a spinal injury. While the client has a neurological condition (cerebral palsy), there is no indication of spinal cord injury or other factors typically associated with reflex incontinence. The clinical signs and small urine voided suggest overflow incontinence, where the bladder fills beyond capacity, rather than reflex incontinence.
• Teach the client to use mobility aids: Teaching mobility aids is not an appropriate intervention for overflow incontinence. Since the primary issue is the inability to empty the bladder fully, mobility aids won’t address the underlying problem. Overflow incontinence requires direct management of the bladder, such as catheterization or bladder training, rather than enhancing mobility.
• Provide skin care: Skin care is critical in clients with incontinence, as wetness can lead to skin irritation and breakdown. Given that the client is in adult diapers and has urinary leakage, skin care must be prioritized. Proper hygiene, moisture management, and the use of skin barriers will help prevent skin damage and infections, which are common complications in clients with urinary incontinence.
• Place an indwelling catheter: Since the client is unable to communicate the need to void and may not empty his bladder fully, placing an indwelling catheter is an appropriate intervention. It will help ensure proper drainage of urine and prevent complications related to overflow incontinence, such as bladder distention, infection, and skin breakdown.
• Blood pressure: Blood pressure monitoring is not directly relevant to the management of overflow incontinence. While important for general health, blood pressure does not provide specific insight into bladder function or urinary incontinence. The focus should be on bladder management and preventing skin breakdown, not blood pressure in this case.
• Post-void residual: Monitoring post-void residual (PVR) is crucial in assessing overflow incontinence. A high PVR indicates that the bladder is not emptying completely, which is characteristic of overflow incontinence. Measuring PVR can guide decisions about catheterization and help track the effectiveness of interventions aimed at improving bladder function.
• Intake and output: Monitoring intake and output is useful in managing fluid balance but does not directly address overflow incontinence. While important for general health, it won’t provide the specific information needed to address bladder function and urinary leakage in the context of overflow incontinence.
• Skin integrity: Skin integrity is a priority in clients with incontinence, as prolonged moisture exposure can lead to skin breakdown and infections. Given that the client is in adult diapers and has wet clothing, regular monitoring and care of the skin are essential to prevent complications like pressure ulcers and dermatitis associated with urinary leakage.