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 D
Explanation
D. Inserting an indwelling catheter involves placing a tube into the bladder through the urethra. The urethra and urinary tract are sterile areas. Sterile gloves are necessary to prevent introducing pathogens into the urinary tract during catheter insertion.
A. An enema involves introducing a solution into the rectum for therapeutic purposes. It does not require the use of sterile gloves because the rectum and lower gastrointestinal tract are not considered sterile areas.
B. Administering an intramuscular injection involves injecting medication into muscle tissue. It does not require sterile gloves unless the site needs to be cleaned with an antiseptic wipe, in which case non- sterile gloves are sufficient.
C. The insertion of a nasogastric tube also does not typically require sterile gloves, as the gastrointestinal tract is not a sterile environment.
Correct Answer is D
Explanation
D. This is the most appropriate goal for a client experiencing diarrhea. Diarrhea is characterized by loose or watery stools, and the goal of treatment is to restore normal stool consistency. This goal focuses on improving the symptoms and resolving the underlying cause of diarrhea, whether it's due to infection, dietary factors, or other reasons.
A. "Defecating regularly" does not necessarily imply improvement in diarrhea symptoms or resolution of the underlying cause. It is vague and does not provide a clear target related to diarrhea management.
B. Increasing ingestion of fruits may be beneficial for some individuals as fruits contain fiber and fluids that can help regulate bowel movements and maintain hydration. However, certain fruits high in fiber (e.g., apples, pears) may exacerbate diarrhea in some cases. This goal should be tailored based on the individual's tolerance and specific dietary needs.
C. This goal is not appropriate for managing diarrhea. Diarrhea leads to fluid loss and dehydration, so limiting fluid intake can worsen dehydration and electrolyte imbalances. Adequate fluid intake is crucial to replace lost fluids and maintain hydration during episodes of diarrhea.
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