An older female resident of a long-term care facility is experiencing frequent episodes of urinary incontinence. Which intervention is best for the nurse to implement with this client?

Decrease time intervals between toileting assistance and encourage Kegel exercises.

Apply disposable undergarments and change frequently to prevent skin breakdown.

Limit fluid intake during the evening meal and throughout the evening hours until bedtime.

Offer emotional support and explain that urinary incontinence is a common occurrence among older women.

Answer and Explanation

The Correct Answer is A

A.   Decreasing the time intervals between toileting can help prevent accidents by ensuring that the resident has more frequent opportunities to use the bathroom. Encouraging Kegel exercises (pelvic floor exercises) can help strengthen the muscles responsible for controlling urination and may improve incontinence.
B.   Using disposable undergarments and changing them frequently can help manage incontinence and protect the skin from irritation and breakdown. However, this intervention primarily addresses the symptoms of incontinence rather than the underlying causes.
C.   Limiting fluid intake in the evening can reduce the likelihood of nocturia (nighttime urination) and may help in managing urinary incontinence. However, reducing fluid intake can also lead to dehydration and other health issues.
D.   Offering emotional support and reassurance is important for the resident’s mental well-being and can help reduce anxiety related to incontinence. Understanding that urinary incontinence is common among older adults can be comforting, but this approach alone does not address the practical management of the condition or contribute to improving urinary control.

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Correct Answer is D

Explanation

A. While avoiding friction can help to prevent skin breakdown, it's not the most important intervention for this client. Frequent position changes are more effective in reducing pressure on the skin and preventing ulcers.
B. Nutrition is important for overall health, but it's not the most immediate concern in this case. Preventing pressure ulcers is the priority.
C. While keeping the skin clean and dry is important, it's not the most effective way to prevent pressure ulcers. Frequent position changes are more important for reducing pressure on the skin.
D. The most effective way to prevent pressure ulcers in immobile clients is to change their position frequently. This helps to relieve pressure on bony areas and promote circulation to the skin. By changing the client's position regularly, the nurse can help to reduce the risk of skin breakdown and the development of pressure ulcers.

A. Document the presence of orthopnea. B. Elevate the head of the bed. C. Obtain a pulse oximeter. D. Assess the client's vital signs.

Correct Answer is B

Explanation

A. Orthopnea is a condition where a person has difficulty breathing when lying flat and may require sitting or standing to breathe more easily. While documenting orthopnea is important for the medical record and understanding the client’s condition, it is not the immediate priority in addressing acute breathing difficulty.
B. Elevating the head of the bed is an immediate and effective action to help alleviate breathing difficulty. This position helps improve respiratory mechanics by allowing the diaphragm to move more freely and reducing pressure on the lungs.
C. Using a pulse oximeter to measure oxygen saturation is important for assessing the client’s oxygen levels and determining the need for supplemental oxygen. However, this action is secondary to immediately addressing the position that is causing difficulty.
D. Assessing vital signs is important for a comprehensive evaluation of the client’s overall condition and to identify any critical changes in health status. However, in the case of immediate breathing difficulty, it is more urgent to take actions that directly address the breathing issue before performing a thorough assessment.

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An older female resident of a long-term care facility is experiencing frequent episodes of urinary incontinence. Which intervention is best for the nurse to implement with this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is B

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