A nurse is contributing to the plan of care for a client who has urinary incontinence.

Which of the following interventions should the nurse include in the plan?

Keep the head of the client's bed elevated to 45".

Limit periods of sitting in a chair to 4 hr.

Use a no-rinse perineal cleanser after incontinence.

Avoid the use of draw sheets for repositioning.

Answer and Explanation

The Correct Answer is C

Urinary incontinence is the involuntary loss of urine, and it can have various causes and contributing factors. When developing a plan of care for a client with urinary incontinence, it is important to address interventions that promote comfort, hygiene, and prevention of complications.

using a no-rinse perineal cleanser after incontinence, is an appropriate intervention for maintaining skin hygiene and preventing skin breakdown. Cleansing the perineal area after episodes of urinary incontinence helps to remove any urine residue and reduce the risk of skin irritation or infection. No-rinse cleansers are often preferred as they are gentle on the skin and do not require rinsing, which can be more convenient for the client.

keeping the head of the client's bed elevated to 45 degrees in (option A) is incorrect because it, is not directly related to managing urinary incontinence. This intervention is typically used for clients at risk for aspiration or to improve respiratory function.

limiting periods of sitting in a chair to 4 hours in (option B) is incorrect because it, may be beneficial to prevent prolonged pressure on the pelvic floor muscles and promote circulation. However, it does not specifically address managing urinary incontinence.

avoiding the use of draw sheets for repositioning in (option D) is incorrect because it, is not directly related to managing urinary incontinence. Draw sheets are commonly used to assist with repositioning and transferring clients.

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Correct Answer is B

Explanation

Isolate children who have varicella until the vesicles have formed crusts.

Isolating children who have varicella, also known as chickenpox, until the vesicles (blisters) have formed crusts is an important infection control measure. Varicella is highly contagious, and the fluid-filled vesicles can easily spread the virus to others. Keeping the child isolated until the vesicles have crusted over helps prevent the spread of the disease.

Children who have erythema infectious, commonly known as fifth disease in (option A) is incorrect because they, do not require short-term antibiotic therapy. Fifth disease is a viral infection caused by parvovirus B19 and is usually a self-limiting condition that resolves on its own without specific treatment.

Administration of childhood immunizations, such as the MMR (measles, mumps, rubella) vaccine in (option C) is incorrect because it, does not prevent exanthem subitem, also known as roseola infantum. Roseola infantum is usually a mild viral illness that primarily affects infants and young children. It is caused by human herpesvirus 6 (HHV-6) or human herpesvirus 7 (HHV-7) and is characterized by high fever followed by a rash.

Restricting fluids for children who have pertussis (whooping cough) in (option D) is not appropriate. In fact, it is important to encourage adequate fluid intake to prevent dehydration, especially in children who may have difficulty eating or drinking due to persistent coughing spells. Pertussis is a bacterial infection, and treatment typically involves antibiotics and supportive care.

A. Avoid discussing the client's fears. B. Offer the client several choices at mealtimes. C. Remind the client of the day and time often. D. Alternate daily caregivers.

Correct Answer is C

Explanation

Delirium is a state of acute confusion and cognitive impairment that can cause disorientation and difficulty with time perception. Reminding the client of the day and time frequently helps provide orientation and reduce confusion. It can help ground the client in reality and improve their understanding of their current circumstances.

A. Avoiding discussing the client's fears can hinder their ability to express and address their concerns. It is important to provide a safe and supportive environment where the client can communicate their fears and feelings.

B. Offering the client several choices at mealtimes might be overwhelming and confusing for someone experiencing delirium. It is generally better to provide structure and simplicity in their meal options, reducing decision-making demands.

D. Alternating daily caregivers can disrupt the continuity of care and increase the client's confusion. Consistency in the caregiving team can help establish a therapeutic relationship and familiarity, which can aid in managing delirium.

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A nurse is contributing to the plan of care for a client who has urinary incontinence.

Which of the following interventions should the nurse include in the plan?