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.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Prolonged grief is characterized by an extended period of mourning and difficulty in accepting the loss. This type of grief is often associated with intense emotional pain and can last for an extended period, beyond what is considered a normal grieving process. In this scenario, the client's inability to accept the loss of their partner after 3 years is indicative of prolonged grief.
Choice B rationale:
Uncomplicated grief refers to a normal grieving process that follows a loss. It typically involves feelings of sadness, anger, and sorrow, but the individual can eventually accept the loss and continue with their life. The client in the scenario is experiencing prolonged and complicated grief, which does not fit the definition of uncomplicated grief.
Choice C rationale:
Anticipatory grief occurs when individuals start grieving before the actual loss takes place, often seen in situations where a loved one has a terminal illness, and the family begins to mourn the eventual loss. The client in the scenario is not experiencing anticipatory grief, as the loss has already occurred.
Choice D rationale:
Disenfranchised grief refers to grief that is not openly acknowledged or socially supported. It occurs when an individual's loss is not recognized or validated by others, such as in the case of the loss of a same-sex partner, a pet, or a non-traditional relationship. In this scenario, the client's grief is not disenfranchised; it is prolonged and complicated.
Correct Answer is D
Explanation
D.The amount of body fat in the subcutaneous tissue decrease with age leading to tagging of skin in the elderly
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