A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took all my money." Which of the following actions should the nurse take?

Answer: C. Change the perineal pad with each void.

Rationale:

A) Cleanse the perineal area from back to front: Cleansing from back to front is not recommended as it increases the risk of introducing bacteria from the anal area to the perineal wound, potentially leading to infection. The correct technique is front-to-back cleansing to prevent contamination.

B) Wash the perineal area with povidone-iodine twice daily: Povidone-iodine is not typically recommended for regular perineal care postpartum, as it can disrupt normal flora and potentially irritate the healing tissues. Using warm water and mild soap is safer for cleansing the area.

C) Change the perineal pad with each void: Changing the perineal pad with each void helps maintain cleanliness and reduces moisture in the perineal area, decreasing the risk of infection and promoting comfort during the healing process of an episiotomy.

D) Wipe the perineal area with a soft cloth: Wiping the area can disrupt the stitches and may cause discomfort. Instead, clients are usually advised to gently pat dry or use a squirt bottle to cleanse, which reduces pressure on the healing tissue.

Compartment syndrome is a condition characterized by increased pressure within a closed anatomical space, such as a compartment in the leg. This increased pressure can compromise blood flow and nerve function. When assessing a client with a long-leg cast who reports severe pain, the nurse should be vigilant for signs and symptoms of compartment syndrome.

Option a is a correct answer because pallor (paleness) in the exposed portion of the left foot may indicate compromised blood flow due to increased pressure within the compartment.

Option b is a correct answer because the inability to move the left foot suggests impaired nerve function,

which can be a sign of compartment syndrome.

Option c is not a correct answer. Increased warmth is not typically associated with compartment syndrome; instead, it may suggest inflammation or infection.

Option d is not a correct answer. Ecchymosis (bruising) is not typically associated with compartment syndrome, as it is more commonly observed in cases of injury or trauma.

Option e is a correct answer because paresthesia (abnormal sensations like tingling or numbness) in the left foot can indicate nerve compression and is a potential symptom of compartment syndrome.

By identifying the presence of pallor, inability to move the foot, and paresthesia, the nurse can recognize indications of compartment syndrome and take appropriate actions to address the condition promptly.