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

Apply a moisture barrier ointment to the area in contact with urine.

Assist with toileting every 4 hr while awake.

Instruct the client to consume fluids between 0600 and 2200.

Cleanse the skin with antibacterial soap and hot water after each incontinence episode.

Answer and Explanation

The Correct Answer is A

A. Apply a moisture barrier ointment to the area in contact with urine: Applying a moisture barrier ointment is an essential intervention to protect the skin from moisture-related irritation and breakdown. This helps prevent skin damage from prolonged exposure to urine.

B. Assist with toileting every 4 hr while awake: While regular toileting is important for managing urinary incontinence, the client should be encouraged to use the bathroom based on individual needs. Toileting every 4 hours may not meet the client’s needs for more frequent voiding.

C. Instruct the client to consume fluids between 0600 and 2200: Limiting fluid intake to specific hours is not recommended unless there is a medical need. Adequate hydration is essential, and restricting fluid intake could lead to dehydration or urinary tract infections.

D. Cleanse the skin with antibacterial soap and hot water after each incontinence episode: Antibacterial soap and hot water can be too harsh on the skin, potentially leading to dryness and irritation. It’s better to use mild soap and warm water to cleanse the skin gently.

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Correct Answer is A

Explanation

A. The client reports frequently having a headache in the morning: Frequent morning headaches can indicate sleep-related issues such as sleep apnea or bruxism (teeth grinding), both of which can significantly affect sleep quality and overall health.

B. The client reports having vivid dreams about their childhood: Vivid dreams can occur naturally, especially during rapid eye movement (REM) sleep. Although they may be unusual, they are not typically a cause for concern.

C. The client reports taking 30 min to fall asleep on average: Taking up to 30 minutes to fall asleep is within normal limits for most people. This is not a concerning finding and does not necessarily require reporting unless the client is experiencing other sleep disturbances.

D. The client reports sleeping about 7 hr on average: Sleeping around 7 hours per night is considered within the normal range for most adults. This is generally adequate sleep, and there is no indication of a significant issue that would require reporting to the provider.

A. "You should try putting the baby in a carrier so you can take a walk when they start crying.” B. "Tell me more about what is going on when the baby starts crying.” C. "Many parents have told me it gets better when the baby is about 3 months old.” D. "As a new parent, you should be enjoying your time with the baby.”

Correct Answer is B

Explanation

A. "You should try putting the baby in a carrier so you can take a walk when they start crying.": This response may not address the client's emotional frustration. It's important to first listen and understand the full context before offering advice.

B. "Tell me more about what is going on when the baby starts crying.": This response shows empathy and invites the client to share more about their experience. It allows the nurse to better understand the situation and provide support or guidance tailored to the client’s concerns.

C. "Many parents have told me it gets better when the baby is about 3 months old.": It's important to explore the client’s current experience and feelings rather than assuming their situation will improve without validating their concerns.

D. "As a new parent, you should be enjoying your time with the baby.": This statement may come across as judgmental as it implies the client should be feeling something different. It is important to acknowledge and validate the client's feelings.

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

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