A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity?

The correct answer is choice A. Ego integrity vs. despair.

Choice A rationale:

Erikson's Theory of Psychosocial Development outlines various stages of development that individuals go through across their lifespan. In the final stage, which occurs in late adulthood, individuals either experience a sense of ego integrity or despair. Ego integrity is characterized by a sense of fulfillment and satisfaction with one's life choices, while despair is marked by feelings of regret and a sense of unfulfillment. The older adult client expressing that their life has no purpose suggests a struggle with finding meaning and satisfaction, aligning with the ego integrity vs. despair stage.

Choice B rationale:

Generativity vs. self-absorption is a stage that occurs during middle adulthood. It involves concerns about contributing to society and the next generation. This stage is not applicable to the scenario described with an older adult who is grappling with a lack of purpose in life.

Choice C rationale:

Identity vs. role confusion is a stage that occurs during adolescence, where individuals explore their sense of self and develop their identities. This stage is not relevant to the older adult client's situation of feeling purposeless.

Choice D rationale:

Intimacy vs. isolation is a stage that typically occurs during young adulthood, where individuals seek close and meaningful relationships with others. This stage is not appropriate for the older adult's feelings of lacking purpose.

The correct answer is Choice A - Measure the client's gastric residual before each feeding.

Choice A rationale:

The nurse's first action in caring for a client receiving intermittent enteral feedings should be to measure the client's gastric residual before each feeding. Gastric residual volume helps assess the client's tolerance to enteral feedings and can indicate delayed gastric emptying or potential complications like aspiration. If the residual volume is high, the nurse can collaborate with the healthcare team to determine whether to hold the feeding, adjust the feeding rate, or take other appropriate actions to ensure the client's safety and optimal nutritional status.

Choice B rationale:

Changing the enteral feeding bag and tubing every 24 hours is important to maintain the sterility and integrity of the feeding system. However, it is not the first action the nurse should take. The priority is to assess the client's tolerance to the feeding by measuring gastric residuals, which helps prevent complications.

Choice C rationale:

Documenting intake and output is a crucial aspect of nursing care for all clients, including those receiving enteral feedings. However, in the context of intermittent enteral feedings, measuring gastric residuals before each feeding is a more immediate and specific action to ensure the client's safety and well-being.

Choice D rationale:

Flushing the tubing with 30 mL of water after each feeding is important to prevent clogging and maintain the patency of the enteral feeding tube. However, this action is secondary to measuring gastric residuals, which directly assesses the client's tolerance to the feedings and helps prevent complications.