The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?
Suggest contacting the healthcare provider for a prescription for catheter insertion.
Recommend a complete bath to cleanse the perineal area more fully.
Evaluate the effectiveness of this measure to stimulate client voiding.
Instruct the PN that this technique promotes infection in elderly females.
The Correct Answer is C
A. Suggest contacting the healthcare provider for a prescription for catheter insertion: Catheter insertion may not be necessary if the client is able to void with this technique. It's important to evaluate less invasive measures first.
B. Recommend a complete bath to cleanse the perineal area more fully: While cleanliness is important, the immediate concern is addressing urinary incontinence and promoting voiding.
C. Evaluate the effectiveness of this measure to stimulate client voiding: Warm water can sometimes stimulate voiding reflexes in clients who have difficulty emptying their bladders. Assessing the client's response to this measure is appropriate.
D. Instruct the PN that this technique promotes infection in elderly females: Pouring warm water over the perineal area does not necessarily promote infection, especially if proper hygiene
measures are followed. It's important to assess the effectiveness of the intervention before assuming it is inappropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale for A: The Health Insurance Portability and Accountability Act (HIPAA) protects the privacy of medical information, and since the client is an adult, medical information can only be shared with the client or individuals the client designates. The nurse must follow these regulations and inform the parent appropriately.
Rationale for B: This response is inappropriate and disrespectful. While maintaining confidentiality is crucial, the language used should be sensitive and professional when discussing privacy issues with a parent.
Rationale for C: While the healthcare provider can discuss medical information, this response deflects responsibility. The nurse should clarify that medical information can only be shared with the client unless permission is granted.
Rationale for D: Offering to share lab results with the parent without the client's consent would violate HIPAA and the client's privacy rights, making this response incorrect.
Correct Answer is C
Explanation
A. Asking the client how often episodes of sundowning are experienced is not relevant to a
functional assessment. Sundowning refers to increased confusion and agitation that typically occurs in the late afternoon or evening and is often associated with dementia.
B. Encouraging the client to lie as still as possible during the assessment may not provide accurate information about the client's functional status. It's important for the client to engage in activities that reflect their typical level of functioning.
C. Questioning the client about the frequency of falls in recent months is an essential component of a functional assessment, especially for an older adult being admitted to a rehabilitation facility.
Understanding the history of falls helps identify potential risk factors and informs the development of an appropriate care plan.
D. Assisting the client with values clarification about end-of-life care options is important but not typically part of a functional assessment focused on evaluating the client's physical and cognitive abilities.
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