A nurse is caring for a client who is incontinent.
Which of the following actions should the nurse take?

Clean the client's skin with hot water.

Dry between folds in the client's skin.

Apply baby powder to the client's skin.

Restrict the client's fluid intake.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Clean the client's skin with hot water. Using hot water to clean a client's skin who is incontinent can be harmful. Hot water can damage the skin and exacerbate any existing skin issues. It is essential to use lukewarm water and gentle, pH-balanced cleansers to prevent skin irritation.

Choice B rationale:

Dry between folds in the client's skin. This is the correct answer. When caring for a client who is incontinent, it is crucial to ensure that the skin is kept clean and dry. Moisture between skin folds can lead to skin breakdown and the development of pressure ulcers. Drying the skin thoroughly helps prevent these issues.

Choice C rationale:

Apply baby powder to the client's skin. Applying baby powder is not recommended, as it can create a moist environment that may promote the growth of fungi and bacteria. It can also potentially lead to respiratory issues if the client inhales the powder. It's better to focus on keeping the skin clean and dry without using powder.

Choice D rationale:

Restrict the client's fluid intake. Restricting the client's fluid intake is not a suitable approach. Adequate hydration is essential for overall health and well-being. Dehydration can lead to various complications and negatively impact the client's overall health. Instead, focus on managing incontinence through appropriate hygiene and the use of incontinence products. .

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Correct Answer is B

Explanation

Choice A rationale:

Increased sensitivity to touch is not typically an age-related change in older adults. In fact, older adults often experience a decrease in sensitivity due to factors like reduced skin elasticity and changes in nerve function.

Choice C rationale:

Increased peripheral vision is not a common age-related change. Visual changes in older adults usually involve decreased visual acuity, difficulties with night vision, and increased sensitivity to glare.

Choice D rationale:

An increase in the size of pupils is not an expected age-related change. Pupils may become smaller and react more sluggishly to changes in light in older adults, but a consistent increase in pupil size is not a common finding.

Choice B rationale:

An increase in cerumen in the ear canal is a common age-related change. Cerumen, or earwax, can accumulate more in older adults due to changes in the composition of earwax and slower migration of earwax out of the ear canal. It can lead to hearing difficulties and may need management. Moving on to the last question.

A. Establish whether the client's grieving is healthy or complicated. B. Develop client-specific goals and outcomes. C. Incorporate the treatment into the client's care. D. Determine whether coping strategies were successful.

Correct Answer is A

Explanation

Choice A rationale:

Establishing whether the client's grieving is healthy or complicated is the first step in the nursing process when caring for a client experiencing grief. This step falls under the assessment phase of the nursing process and is essential for understanding the client's needs and planning appropriate care.

Choice B rationale:

Developing client-specific goals and outcomes comes after the assessment phase in the planning stage of the nursing process. While important, it is not the first action the nurse should take in this situation.

Choice C rationale:

Incorporating the treatment into the client's care occurs during the implementation phase of the nursing process and follows assessment and planning. This is not the first action.

Choice D rationale:

Determining whether coping strategies were successful is part of the evaluation phase of the nursing process, which occurs after the implementation of care. It is not the first step in this situation. Now, let's proceed to the final question.

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A nurse is caring for a client who is incontinent. Which of the following actions should the nurse take?

Nursing Test Bank

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A nurse is caring for a client who is incontinent.
Which of the following actions should the nurse take?