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 B
Explanation
A. While involving a spiritual advisor may be helpful, the nurse’s priority is to ensure the client is fully informed before decisions are made.
B. Providing all relevant information allows the client to weigh risks and options and make an informed decision respecting their beliefs.
C. Forcing information or pressuring the client disregards their autonomy and beliefs.
D. Having the client sign refusal without thorough discussion does not support informed consent or shared decision-making.
Correct Answer is C
Explanation
A. Asking the client to explain without language support may lead to miscommunication and incomplete information.
B. The neighbor may not have accurate or complete details and is not a reliable source for medical information.
C. Arranging for a professional interpreter ensures accurate and confidential communication, respecting the client’s rights.
D. Family members may unintentionally filter or alter information and might not be appropriate interpreters for medical details.
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