Which of the following are essential in the care for a patient with incontinence-associated dermatitis? (SELECT ALL THAT APPLY)
apply warm compresses to relieve discomfort
check the client's skin for moisture at least q 2 hrs
use a moisture barrier product after cleansing
decrease oral intake in early morning
dry the skin with a vigorous motion to promote circulation
Correct Answer : A,B,C
A. Applying warm compresses can help relieve discomfort
B. Regular monitoring of skin moisture is crucial in managing IAD. Moist skin is more susceptible to breakdown, so frequent checks allow for prompt intervention, such as changing incontinence products or applying protective barriers.
C. Applying a moisture barrier product after cleansing helps protect the skin from moisture and irritants found in urine or feces. These products create a protective barrier that can prevent further damage and promote healing of already affected skin. This is essential in managing IAD.
D There is no clinical
Rationale to decrease oral intake in the early morning specifically for managing IAD. Hydration is important for overall skin health, and reducing oral intake without medical indication could lead to dehydration, which may worsen skin condition.
E. Vigorous drying of the skin is not recommended as it can exacerbate skin irritation and damage. Instead, gentle patting or air drying is preferred to avoid further trauma to the already compromised skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Negligence in nursing refers to the failure to provide care that meets established standards, resulting in harm to the patient. In this case, if the nurse failed to monitor vital signs as per hospital policies and this failure led to complications for the post-operative client, it could constitute negligence. Negligence involves breaching the duty of care owed to the patient, causing harm that could have been reasonably prevented.
B. Nonmaleficence is the principle of doing no harm. While it is an ethical principle guiding healthcare practice, it does not justify or excuse negligence. Negligence involves a failure to uphold the duty of care owed to the patient, resulting in harm due to substandard practice.
C. A misdemeanor typically refers to a lesser criminal offense. Negligence in healthcare generally does not rise to the level of a criminal offense like a misdemeanor unless there is gross negligence or willful misconduct. In most cases, negligence leading to harm is addressed through civil litigation rather than criminal charges.
D. While negligence can certainly be considered unethical behavior in the context of healthcare, negligence itself is a legal concept related to professional malpractice rather than solely an ethical breach. Ethical violations may involve different aspects of professional conduct not directly related to negligence, such as breaches of confidentiality or conflicts of interest.
Correct Answer is B
Explanation
B Leaning away from the client can convey disinterest, distraction, or a lack of engagement. It creates physical distance and may inhibit the client from feeling heard or valued. Thus, leaning away from the client can be a barrier to active listening as it diminishes the nurse's ability to fully attend to and understand the client's message.
A. An open posture, where the nurse's body is facing the client with arms uncrossed and relaxed, signals openness and receptivity. It encourages communication and shows the client that the nurse is engaged and attentive. Therefore, an open posture promotes active listening rather than serving as a barrier.
C. Eye contact is essential for effective communication and active listening. It demonstrates attentiveness, interest, and respect. Establishing eye contact helps the nurse to connect with the client and encourages them to continue sharing their thoughts and feelings. Therefore, eye contact supports active listening rather than hindering it.
D. Sitting squarely facing the client promotes engagement and shows that the nurse is focused on the client. It facilitates direct communication and helps the nurse to observe the client's nonverbal cues effectively. This posture encourages open dialogue and supports active listening rather than acting as a barrier.
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