The home health nurse is caring for an older adult client living alone at home who is incontinent of urine and changes the adult diaper (pad) daily. The nurse plans care based on which nursing concern?
altered skin integrity risk
risk
activity intolerance risk
falls risk
The Correct Answer is A
A. Incontinence and infrequent changing of adult diapers increase the risk of altered skin integrity, such as skin breakdown or pressure ulcers, due to prolonged exposure to moisture and irritation.
B. The Answer seems incomplete ("risk") and does not specify the type of risk.
C. Activity intolerance is not directly related to incontinence or diaper use.
D. While falls risk is important in older adults, it is not the primary concern related to incontinence and diaper changing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. High-calorie, high-protein supplements are typically not clear liquids and may be too heavy.
B. Hot cereals and ice cream are not clear liquids; chocolate milk is opaque.
C. Milk and egg substitutes are opaque and not part of a clear liquid diet.
D. Gelatin desserts, carbonated beverages, and apple juice are clear liquids that are transparent and allowed on a clear liquid diet.
Correct Answer is D
Explanation
A. Nurses provide support but do not usually decide disclosure.
B. Clergy may offer spiritual support but do not decide medical disclosure.
C. Family members may want to be involved but don’t have the primary responsibility.
D. The health care provider is typically responsible for deciding what, when, and how to disclose the diagnosis to the client.
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