A nurse is contributing to the plan of care for a client who has urinary incontinence.

Which of the following interventions should the nurse include in the plan?

Keep the head of the client's bed elevated to 45".

Limit periods of sitting in a chair to 4 hr.

Use a no-rinse perineal cleanser after incontinence.

Avoid the use of draw sheets for repositioning.

Answer and Explanation

The Correct Answer is C

Urinary incontinence is the involuntary loss of urine, and it can have various causes and contributing factors. When developing a plan of care for a client with urinary incontinence, it is important to address interventions that promote comfort, hygiene, and prevention of complications.

using a no-rinse perineal cleanser after incontinence, is an appropriate intervention for maintaining skin hygiene and preventing skin breakdown. Cleansing the perineal area after episodes of urinary incontinence helps to remove any urine residue and reduce the risk of skin irritation or infection. No-rinse cleansers are often preferred as they are gentle on the skin and do not require rinsing, which can be more convenient for the client.

keeping the head of the client's bed elevated to 45 degrees in (option A) is incorrect because it, is not directly related to managing urinary incontinence. This intervention is typically used for clients at risk for aspiration or to improve respiratory function.

limiting periods of sitting in a chair to 4 hours in (option B) is incorrect because it, may be beneficial to prevent prolonged pressure on the pelvic floor muscles and promote circulation. However, it does not specifically address managing urinary incontinence.

avoiding the use of draw sheets for repositioning in (option D) is incorrect because it, is not directly related to managing urinary incontinence. Draw sheets are commonly used to assist with repositioning and transferring clients.

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Correct Answer is A

Explanation

Do you have any plan for harming yourself?

When a client expresses suicidal ideations, the nurse's priority is to assess whether the client has a specific plan for harming themselves. This question helps determine the level of immediate risk and guides the nurse's actions in providing appropriate interventions and ensuring the client's safety.:

Can you tell me about the stresses in your life? In (option B) is incorrect. While understanding the client's stressors is important in assessing their overall mental health, it may not be the priority question in this situation. The immediate concern is to assess the presence of a specific plan for self-harm.

Do you have someone to discuss your feelings with? In (option C) is incorrect. Having someone to talk to about feelings can be beneficial for the client, but it is not the priority question in this situation. The primary focus is to assess the client's immediate risk and take appropriate actions to ensure their safety.

Has anyone in your family ever died by suicide? In (option D) is incorrect. Family history of suicide can be a risk factor for suicidal ideation, but it is not the priority question in this scenario. Assessing the client's current risk and immediate plan for self-harm is more crucial to determine the necessary interventions.

A. A recent move to a new city B. Report feeling depressed C. Lack of nutritional knowledge D. Recurring urinary tract infections

Correct Answer is A

Explanation

Stressors can be categorized as external or internal. External stressors are factors or events in the environment that can cause stress.
In this case, the recent move to a new city is an external stressor because it is an event that has occurred outside of the client and is influencing their current state of stress. Moving to a new city can bring about significant changes and challenges, such as adjusting to a new environment, finding new social connections, and adapting to unfamiliar surroundings.
B. Feeling depressed is an internal stressor because it relates to the client's emotional state or mental health condition. Depression can be caused by various factors, such as biochemical imbalances, life circumstances, or genetic predispositions.

C. Lack of nutritional knowledge: This is an internal stressor because it refers to the client's lack of knowledge or awareness regarding nutrition. While the lack of nutritional knowledge can contribute to stress, it is an internal factor that can be addressed through education and learning.
D. While recurring urinary tract infections can be stressful for the client, they are considered an internal stressor because they involve a physical condition or health issue within the client's body. Addressing and managing the infections would involve medical interventions and possibly lifestyle modifications.

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A nurse is contributing to the plan of care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the plan?

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A nurse is contributing to the plan of care for a client who has urinary incontinence.

Which of the following interventions should the nurse include in the plan?