A client has urinary incontinence. Which assessment finding indicates that outcomes for a priority nursing diagnosis have been met?
The client reports drinking 8 to 9 glasses of water each day.
The client expresses satisfaction with undergarments for incontinence.
The family states that the client is more active and socializes more.
The skin in the perineal area is intact without redness upon inspection.
The Correct Answer is D
Choice A rationale:
While adequate hydration is important for overall health and urinary function, it does not directly address the priority nursing diagnosis of urinary incontinence. Increased fluid intake without addressing the underlying incontinence can actually exacerbate the problem by increasing urine output.
It's crucial to assess for signs of urinary retention or incomplete bladder emptying, as excessive fluid intake can worsen these conditions.
Individualized fluid intake goals should be established based on the client's overall health status, bladder capacity, and fluid balance.
Choice B rationale:
Satisfaction with incontinence products can improve comfort and quality of life, but it does not necessarily indicate that the underlying issue of incontinence has been resolved.
It's important to evaluate the effectiveness of incontinence products in managing leakage and preventing skin breakdown, but they should not be considered a definitive solution for incontinence.
Explore other interventions to address the root cause of incontinence, such as bladder training, pelvic floor muscle exercises, or medications.
Choice C rationale:
Increased activity and socialization can be positive outcomes of effective incontinence management, but they are not direct measures of the priority nursing diagnosis.
Improved social engagement and activity levels might reflect a reduction in incontinence episodes and increased confidence, but they should not be the sole indicators of success.
Assess for specific changes in incontinence frequency, severity, and impact on daily life to more accurately gauge progress.
Choice D rationale:
Intact, healthy skin in the perineal area is a direct and objective indicator that a priority nursing diagnosis of urinary incontinence has been met.
It demonstrates that the interventions implemented to manage incontinence have been effective in preventing skin breakdown and irritation, which are common complications of incontinence.
This finding aligns with the goal of maintaining skin integrity and preventing infection, which are essential aspects of incontinence care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
Step 1: Divide the total volume of fluid (2000 ml) by the total time in hours (24 hours). Step 2: Perform the calculation: 2000 ml ÷ 24 hours = 83.33 ml/hour.
Step 3: Round the answer to the nearest whole number, as fluid administration is typically measured in whole milliliters.
The correct answer is 83 ml/hour.
Correct Answer is B
Explanation
Choice A rationale:
While advancing age is a significant risk factor for cancer, it is not considered the single biggest risk factor. The risk of developing cancer does increase with age, primarily due to the accumulation of DNA damage over time. This damage can arise from various sources, including exposure to carcinogens, errors in DNA replication, and oxidative stress. With age, the body's ability to repair DNA damage also declines, making cells more susceptible to cancerous changes.
However, it's important to note that cancer can develop at any age, and even younger individuals can be affected if exposed to other significant risk factors.
Choice B rationale:
Exposure to tobacco is widely recognized as the single biggest risk factor for developing cancer. It is estimated to be responsible for about 25-30% of all cancer deaths worldwide.
Tobacco smoke contains over 70 known carcinogens, which are substances that can damage DNA and lead to cancer. These carcinogens can affect various organs in the body, including the lungs, mouth, throat, esophagus, stomach, pancreas, liver, bladder, kidney, cervix, and colon.
The risk of cancer increases with the amount and duration of tobacco use. Even exposure to secondhand smoke can increase the risk of cancer.
Quitting tobacco use is the most effective way to reduce the risk of cancer.
Choice C rationale:
Exposure to occupational chemicals is a known risk factor for certain types of cancer, such as lung cancer, bladder cancer, and leukemia. However, it is not considered the single biggest risk factor for developing cancer overall.
The risk of cancer from occupational chemicals depends on the specific chemical, the level of exposure, and the duration of exposure.
Workplace safety measures, such as using protective equipment and limiting exposure to hazardous chemicals, can help reduce the risk of cancer.
Choice D rationale:
Infection with certain viruses, known as oncoviruses, can increase the risk of developing certain types of cancer. For example, infection with human papillomavirus (HPV) can increase the risk of cervical cancer, and infection with hepatitis B virus (HBV) can increase the risk of liver cancer.
However, oncoviruses are not considered the single biggest risk factor for developing cancer overall. Vaccines are available to protect against some oncoviruses, such as HPV and HBV.
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