An older adult client residing in a long-term care facility has become disoriented and suddenly develops urinary incontinence. Which intervention should the nurse implement?

Obtain a clean, voided urine specimen for analysis.

Evaluate the client's response to bladder training efforts.

Place a protective undergarment on the client.

Encourage increased fluid intake for 24 hours.

Answer and Explanation

The Correct Answer is A

A.   Urinary incontinence in an older adult can be a symptom of various underlying conditions, such as urinary tract infections, dehydration, or cognitive impairment. Obtaining a urine specimen for analysis can help to identify the underlying cause of the incontinence and guide appropriate treatment.
B.   Bladder training is a technique used to improve bladder control and reduce incontinence. However, it's not appropriate to evaluate the client's response to bladder training efforts when they have suddenly become disoriented and developed incontinence. This suggests a potential underlying medical condition that needs to be addressed first.
C.   While protective undergarments can be helpful in managing incontinence, they do not address the underlying cause of the problem. It's important to identify and treat the underlying condition to improve the client's quality of life and prevent complications.
D.   While dehydration can sometimes contribute to incontinence, it's not appropriate to increase fluid intake in a client who has suddenly become disoriented. This could worsen their condition, especially if they have cognitive impairment or other underlying medical conditions.

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Correct Answer is C

Explanation

A. While napping can be beneficial for some people, a nap of 15 minutes may not address the root causes of the client’s sleep difficulties, such as stress and chronic headaches. Additionally, napping during the day can sometimes interfere with nighttime sleep.
B. Reducing or eliminating stressful situations is a valuable goal for improving overall well-being and sleep quality. However, this recommendation is often not immediately actionable or practical, as stressors in life can be difficult to eliminate completely. It’s more effective to focus on identifying and managing stress through practical and immediate interventions.
C. Assessing the client's sleep and activity patterns is a critical step in identifying potential causes of sleep disturbances. Understanding the client’s current sleep habits, daily routines, and factors affecting their sleep can help in developing an effective plan of care.
D. While medication might be necessary for some clients, it should not be the first line of intervention without a thorough assessment. PRN (as needed) medications for stress might not address the root causes of sleep issues and could potentially lead to dependence or other side effects.

A. Use background music to promote relaxation. B. Turn on overhead lights while reviewing instructions. C. Stand behind the client to avoid intimidation. D. Provide handouts written at a 12th grade reading level.

Correct Answer is D

Explanation

A. While music can be relaxing, it may also be distracting and make it difficult for the client to focus on the instructions.
B. Bright overhead lights can be uncomfortable and may even cause strain on the eyes. It's generally better to use soft, natural lighting when reviewing instructions.
C. Standing behind the client can make them feel intimidated or uncomfortable, especially if they are already feeling anxious or overwhelmed. It's better to stand in front of the client and maintain eye contact to show that you are engaged and attentive.
D. Older adults may have difficulty understanding written information that is too complex. Providing handouts written at a 12th grade reading level ensures that the client can easily comprehend the instructions and follow them at home.

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An older adult client residing in a long-term care facility has become disoriented and suddenly develops urinary incontinence. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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