A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?

Contact the client's caregiver to discuss the client's comment.

Review the medical record to see if the client has reported abuse in the past.

Report the suspected abuse to the nurse manager.

Restrict family members from visiting with the client.

Answer and Explanation

The Correct Answer is B

A. Contacting the client's caregiver to discuss the client's comment might be helpful in some situations, but the priority in this scenario is to assess the possibility of abuse or mistreatment, not to confront the caregiver immediately.

B. Reviewing the medical record to see if the client has reported abuse in the past is correct. The nurse should first gather relevant information to understand the context of the client's statement. If the client has a history of reporting abuse or signs of mistreatment, it may provide critical insight.

C. Reporting suspected abuse to the nurse manager could be necessary if abuse is confirmed, but it is important to first assess the situation and gather information before making such a report.

D. Restricting family members from visiting with the client is an extreme response without any evidence of abuse. The nurse should assess the situation further before taking such action.

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Correct Answer is D

Explanation

A. "I will increase my fluid intake to 1,700 milliliters per day.": While maintaining hydration is important for people with COPD, 1,700 milliliters may not be sufficient for all individuals. Fluid intake should be tailored to the patient's needs, and the client should be advised to follow specific guidelines from their provider.

B. "I should do aerobic exercises once per day.": This is somewhat correct, as regular exercise is beneficial for people with COPD, but it should be individualized based on the client's current condition and limitations. However, exercise should not be the primary focus of initial teaching for someone newly diagnosed with COPD.

C. "I will consume low-protein, low-calorie foods.": This is incorrect. COPD clients generally need a balanced diet with sufficient protein and calories to support respiratory function and muscle strength. A low-calorie diet may contribute to weight loss and muscle wasting, which can worsen COPD symptoms.

D. "I should practice pursed-lip breathing exercises.": This is correct. Pursed-lip breathing helps to control shortness of breath, improve ventilation, and reduce the work of breathing, which is an important strategy for individuals with COPD to manage their condition.

A. Denial B. Sublimation C. Regression D. Repression

Correct Answer is B

Explanation

A. Denial is incorrect. Denial involves refusing to acknowledge reality or a distressing situation, which is not evident in this scenario. The adolescent is aware of the conflict and has chosen a constructive way to address it.

B. Sublimation is correct. Sublimation is the process of channeling unacceptable impulses (such as frustration or aggression) into socially acceptable activities (such as sports or creative pursuits). By joining the track and field team instead of arguing with his brothers, the adolescent is redirecting energy into a positive outlet.

C. Regression is incorrect. Regression occurs when an individual reverts to an earlier stage of development in response to stress. Examples include an older child suddenly sucking their thumb or having temper tantrums. The adolescent in this scenario is demonstrating maturity, not regression.

D. Repression is incorrect. Repression involves unconsciously blocking distressing thoughts or emotions from awareness. The adolescent is not avoiding or forgetting about the conflict but is instead managing it through physical activity.

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A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?

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A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?