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 A

Explanation

A. This action is appropriate given that the client’s posture is upright and their gait is smooth and steady. If the client demonstrates safe ambulation and is capable of performing ADLs effectively, documenting this observation is crucial for maintaining a record of their functional status.
B. Initiating a fall risk protocol may not be immediately necessary if the client shows a smooth, steady gait and upright posture. However, fall risk assessments are generally based on multiple factors, including history of falls, medication side effects, and environmental hazards.
C. The client’s smooth and steady gait suggests they are ambulating effectively. Teaching the client to shorten their stride is typically advised when there is observed instability or an increased risk of falls.
D. Assessing the client's activity tolerance is a valid consideration, but it may not be the immediate next step if the client’s gait and posture are already observed to be steady and upright.

A. Compare the client's manifestations with the defining criteria of related problems. B. List the nursing actions that need to be implemented most immediately. C. Review the priority nursing problems included in the plan of care. D. Ensure that all treatments prescribed by the healthcare provider have been initiated.

Correct Answer is C

Explanation

A. This action involves assessing how the client’s current symptoms and manifestations align with the criteria of the nursing problems identified. By doing this, the nurse can ensure that the goals set are directly related to addressing these specific issues.
B. While prioritizing nursing actions is important for immediate care needs, listing these actions is more related to the implementation phase rather than the goal-setting phase. Goals are broader and focus on what outcomes are desired for the client, while nursing actions are specific steps taken to achieve those goals.
C. Reviewing the priority nursing problems helps in identifying the most urgent issues that need to be addressed. This review is essential for setting appropriate goals, as it ensures that the goals reflect the most pressing needs of the client.
D. Ensuring that prescribed treatments have been initiated is part of the implementation phase of care. While it is important for the overall management of the client’s health, this step does not directly involve goal setting.

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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

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

Correct Answer is A

Explanation

When identifying the goals to be included in a client's plan of care, the nurse should take which action?

Correct Answer is C

Explanation

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

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