A nurse is caring for a client who has a prescription for 81 mg acetylsalicylic acid (Aspirin) daily.
Which of the following actions should the nurse plan to take?

Choice A rationale

Requesting an indwelling urinary catheter is highly discouraged for managing incontinence in clients with dementia due to the significant risk of Catheter-Associated Urinary Tract Infections (CAUTIs). The catheter provides a conduit for microbial entry, bypassing normal defense mechanisms, thus dramatically increasing morbidity and potentially mortality in the elderly.

Choice B rationale

Using adult diapers as a primary strategy for incontinence can negatively impact skin integrity, leading to moisture-associated dermatitis and pressure injuries due to prolonged contact with urine. Furthermore, this approach fails to engage any remaining bladder control or cognitive function, potentially hastening dependency.

Choice C rationale

Implementing an every-2-hr toileting schedule (timed voiding) is a behavioral intervention that bypasses the need for the client with dementia to verbally communicate the urge to void, which is often impaired. This proactive strategy prevents the bladder from becoming over-distended, thereby reducing the likelihood of a high-volume incontinence episode.

Choice D rationale

Reminding a client with dementia to communicate the need to void is ineffective because their cognitive impairment, particularly in the cerebral cortex, often disrupts the neuronal pathways necessary for sensing bladder fullness and executing the motor and verbal request for assistance. This approach does not address the underlying neurological deficit.

Choice A rationale

Gonorrhea is caused by the bacterium Neisseria gonorrhoeae, not a virus, and it is curable with appropriate antibiotic therapy, such as ceftriaxone. Informing the client that it is a virus and incurable provides false and misleading information, which could lead to non-adherence to treatment and continued transmission of the infection to sexual partners.

Choice B rationale

The presence of a chancre, or primary lesion, is the hallmark clinical manifestation of primary syphilis, an infection caused by the spirochete Treponema pallidum. Although both are sexually transmitted infections, gonorrhea typically presents with urethritis, cervicitis, or pharyngeal infection, not a chancre, which makes this assessment finding irrelevant to a diagnosis of gonorrhea.

Choice C rationale

Public health mandates and ethical responsibilities require the nurse to conduct thorough contact tracing for sexually transmitted infections like gonorrhea. Obtaining information about the client's recent sexual partners is vital so that they can be notified, tested, and treated, preventing further disease propagation and potential long-term complications, such as pelvic inflammatory disease.

Choice D rationale

A diaphragm is a barrier method primarily used for contraception and offers minimal protection against sexually transmitted infections like gonorrhea because it does not cover the external genitalia. The nurse should instruct the client on the consistent and correct use of condoms (male or female) as the most effective barrier method for preventing reinfection and transmission. 80mm.5pt.