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

Answer and Explanation

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.

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Correct Answer is D

Explanation

D. Congruent communication occurs when verbal and nonverbal messages are consistent with each other. In the scenario, the nurse's direct eye contact, pleasant expression, and verbal statement ("The colostomy looks good") appear to be aligned and supportive of each other. This demonstrates congruence in communication, where both verbal and nonverbal cues are reinforcing a positive message to the client.

A. Introductory communication typically refers to the initial phase of interaction where the nurse establishes rapport, introduces themselves, and sets the tone for the interaction. This does not directly apply to the nurse's actions described in the scenario of changing a client's colostomy bag.

B. Noncongruent communication occurs when there is a mismatch between verbal and nonverbal messages. In this scenario, the nurse makes direct eye contact, has a pleasant expression, and verbally reassures the client that "the colostomy looks good." If these nonverbal cues (eye contact, pleasant expression) are not aligned with the verbal message (reassuring statement), it would be noncongruent communication. However, based on the scenario, it seems the nurse's nonverbal cues (eye contact, pleasant expression) support the verbal message, so this option is less likely.

C. Nonverbal communication includes gestures, facial expressions, eye contact, body language, and tone of voice. In the scenario described, the nurse demonstrates nonverbal communication by making direct eye contact and having a pleasant expression while interacting with the client. Nonverbal communication is an important aspect of nursing care as it conveys empathy, reassurance, and attentiveness to the client's needs.

Correct Answer is ["16"]

Explanation

Total Volume (ml) / Rate (ml/hr) = Time (hr).

For a client receiving 2 liters of IV fluid at a rate of 125 ml/hr,

Convert liters to milliliters (since 1 liter = 1000 ml, therefore 2 liters = 2000 ml). Then, divide the total volume by the rate: 2000 ml / 125 ml/hr = 16 hours.

So, the nurse should expect the IV fluids to last for 16 hours.

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Which of the following are essential in the care for a patient with incontinence-associated dermatitis? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse makes direct eye contact and has a pleasant expression on her face when changing a client's colostomy bag. The nurse tells the client, "The colostomy looks good." What type of communication is the nurse demonstrating?

Correct Answer is D

Explanation

A client is to receive 2 liters of IV fluid at 125 ml/hr. How long should the nurse expect the IV fluids to last? Document number of hours.

Correct Answer is ["16"]

Explanation

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