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 C
Explanation
Choice A rationale:
Dysphagia is a difficulty or discomfort with swallowing and is not a complication of diverticulitis. Diverticulitis typically involves inflammation or infection of diverticula in the colon and may present with symptoms such as abdominal pain, fever, and changes in bowel habits, but dysphagia is not a characteristic feature.
Choice B rationale:
Ulcerative colitis is a distinct inflammatory bowel disease and is not a complication of diverticulitis. These conditions have different causes and affect different parts of the digestive tract. While both conditions can cause abdominal discomfort, they are not directly related.
Choice C rationale:
Peritonitis is a potential complication of diverticulitis. When diverticula become infected and rupture, they can spill their contents into the abdominal cavity, leading to peritonitis, which is an inflammation of the peritoneum (the lining of the abdominal cavity). This condition can be life-threatening and requires prompt medical intervention.
Choice D rationale:
Crohn's disease is a separate inflammatory bowel disease and is not a complication of diverticulitis. Crohn's disease can affect any part of the digestive tract, whereas diverticulitis typically occurs in the colon. They have distinct clinical features and treatment approaches. .
Correct Answer is D
Explanation
Choice A rationale:
Decreased thickness of tympanic membranes is not a typical physiological change in older adults. Tympanic membranes tend to become thinner and less flexible with age, leading to increased susceptibility to damage, not decreased thickness.
Choice B rationale:
Decreased tinnitus is not a physiological change related to aging. Tinnitus can occur in individuals of all ages and is often associated with various factors such as exposure to loud noises, ear infections, or underlying medical conditions.
Choice C rationale:
Decreased ear wax is not a typical physiological change in older adults. In fact, older adults may experience increased production of earwax, which can lead to hearing problems if not managed appropriately.
Choice D rationale:
Decreased ability to hear high-frequency sounds is a common physiological change in older adult clients. This change, known as presbycusis, is characterized by a reduced ability to hear high-pitched sounds due to changes in the inner ear, including damage to hair cells and changes in the auditory nerves. Presbycusis is a well-documented and expected age-related change in hearing.
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