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. Lack of power refers to feelings of helplessness but does not directly address the expressed desire to no longer live.
B. Fear may be present but is not the primary concern expressed.
C. Sexual impairment is unrelated to the client’s statement about meaning and desire to live.
D. The client’s statement indicates suicidal ideation, making self-harm risk the most appropriate nursing concern to address.
Correct Answer is B
Explanation
A. Older adults often have shallower breathing due to decreased lung elasticity.
B. Even occasional smoking can lead to addiction because nicotine is highly addictive; this statement is incorrect.
C. An upright position facilitates easier breathing by improving lung expansion.
D. Physically fit individuals typically have more efficient and slower breathing rates than sedentary individuals.
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