A nurse evaluates the plan of care for an older adult client with urinary incontinence and early signs of skin irritation on the sacral area. Which of the following actions should the nurse recommend modifying first?
The client is turned every 3 hours during the night
The client receives assistance with perineal care after each incontinence episode
The client wears cotton adult briefs at all times
The client is encouraged to increase fluid intake
The Correct Answer is C
A. The client is turned every 3 hours during the night: Regular repositioning helps prevent pressure injuries and skin breakdown. Turning every 3 hours is appropriate and should be maintained.
B. The client receives assistance with perineal care after each incontinence episode: Prompt perineal care is essential to reduce moisture, prevent skin irritation, and maintain skin integrity. This intervention should continue as planned.
C. The client wears cotton adult briefs at all times: Continuous use of briefs, even if cotton, can trap moisture against the skin, worsening irritation and increasing the risk of pressure injuries. The nurse should modify this plan, recommending briefs be removed when not necessary and using barrier creams or pads to protect the skin.
D. The client is encouraged to increase fluid intake: Adequate hydration helps maintain urinary health and prevents concentrated urine, which can irritate the skin. Encouraging fluid intake should remain part of the care plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Appetite: The client ate only 10% of breakfast and reports no appetite, indicating no improvement in nutritional intake. Poor appetite remains a concern, as it can delay recovery and affect strength.
B. Wandering: There is no indication that wandering behavior has decreased, so this finding does not show improvement.
C. Sleep/wake cycle: The client’s ability to fall asleep around 0530 and sleep until 0900 indicates an improvement in the sleep-wake cycle. Previously, the client was awake and restless throughout the night, experiencing nightmares and agitation.
D. Blood pressure: The blood pressure has improved from previous low readings (e.g., 90/58 mm Hg) to 115/58 mm Hg at 0900, indicating better hemodynamic stability. This improvement suggests the client’s cardiovascular status is stabilizing.
E. Daytime orientation: At 0900, the client is oriented x3 (person, place, time) compared to previous disorientation and confusion during the night. This improvement in cognitive status reflects resolving delirium or acute confusion, signaling progress in neurological function.
Correct Answer is A
Explanation
A. Recommend the use of a walker or cane to assist with mobility: Mobility aids provide stability, improve balance, and reduce fall risk in older adults with gait difficulties. Proper instruction on their use helps the patient maintain independence while preventing injury from frequent falls.
B. Advise the patient to avoid physical activity to prevent falls: Avoiding activity leads to deconditioning, muscle weakness, and joint stiffness, which actually increase fall risk over time. Promoting safe mobility rather than restriction is a better approach in geriatric care.
C. Instruct the patient to only move around when someone is available to assist: While supervision can enhance safety, limiting independent movement reduces autonomy and may not be practical at home.
D. Suggest wearing loose-fitting shoes for comfort: Loose shoes increase the risk of tripping and instability. Well-fitting, supportive footwear with nonslip soles is recommended to reduce fall risk.
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