A nurse is caring for a client who is incontinent of urine. Which of the following actions should the nurse take?
Rinse the client's skin with hot water.
Keep the clients skin area moist.
Apply barrier cream to the client's cleansed skin.
Apply a thin layer of cornstarch to the client's skin.
The Correct Answer is C
A. Rinse the client's skin with hot water: Hot water can damage the skin’s protective barrier, causing irritation and increasing the risk of breakdown. Using lukewarm water is safer and helps maintain skin integrity while cleansing the area.
B. Keep the client’s skin area moist: Excess moisture from urine or feces contributes to maceration and increases the risk of skin breakdown. The skin should be kept clean and dry, not intentionally moist, to prevent irritation and pressure injury.
C. Apply barrier cream to the client's cleansed skin: Barrier creams protect the skin from prolonged exposure to urine and stool, helping to prevent incontinence-associated dermatitis. Applying the cream after cleansing creates a protective layer, maintaining skin integrity and reducing irritation.
D. Apply a thin layer of cornstarch to the client's skin: Cornstarch can clump when in contact with moisture and may promote fungal growth. It is not recommended for protecting skin from incontinence-related irritation and may worsen skin breakdown.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Veracity: Veracity refers to the ethical principle of being truthful with clients. While honesty is important in nursing, providing a meal to the client addresses their immediate physiological need rather than demonstrating truthfulness.
B. Boundary crossing: Boundary crossing occurs when a nurse engages in actions that deviate from professional limits, potentially for personal or emotional reasons. In this case, providing food to meet a basic client need does not constitute a boundary violation.
C. Countertransference: Countertransference happens when a nurse projects personal feelings onto a client, which can interfere with care. The nurse’s action here is intentional and focused on meeting the client’s needs, not influenced by personal unresolved emotions.
D. Promoting trust: Interrupting the bath to ensure the client receives nourishment demonstrates the nurse’s attentiveness, responsiveness, and prioritization of the client’s well-being. This action fosters a therapeutic relationship and builds trust between the nurse and client.
Correct Answer is D
Explanation
A. Social withdrawal: Social withdrawal is common in Alzheimer's disease and may indicate depression or disease progression. While important to address, it does not pose an immediate safety risk.
B. Inability to remember their partner’s name: Memory loss is a hallmark of Alzheimer's disease. Forgetting familiar names requires monitoring and supportive strategies but is not an urgent safety concern.
C. Difficulty articulating words: Language difficulties can affect communication and quality of life, but they do not immediately endanger the client. Interventions focus on speech therapy and alternative communication methods.
D. Wandering outside at night: Wandering exposes the client to hazards such as getting lost, traffic accidents, or injury, making it a priority safety concern. Immediate intervention is necessary to protect the client and prevent harm.
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