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 D

Explanation

A. Artificial flowers in the room: While artificial flowers can harbor dust and allergens, they are not a significant risk factor for infection in a neutropenic client with HIV. The primary concern is bacterial or fungal exposure, which is unlikely to be significantly affected by artificial flowers.Still, due to the need for a highly sterile environment for neutropenic patients, artificial flowers are typically avoided in clinical settings.

B. Room with negative airflow: A room with negative airflow is designed to prevent airborne pathogens from spreading outside the room. However, this measure is more relevant for clients with contagious respiratory infections (e.g., tuberculosis).

C. Meal tray with hard-boiled eggs: Hard-boiled eggs are generally safe for most clients. However, in a neutropenic client, the risk lies more in raw or undercooked eggs due to potential bacterial contamination (e.g., Salmonella). Hard-boiled eggs are fully cooked and less likely to pose a significant risk.

D. Meal tray with ice cream and fresh fruit: This choice presents a higher risk. Neutropenic clients should avoid fresh fruits (especially unwashed) due to potential bacterial and fungal contamination. Ice cream, although pasteurized, can also harbor bacteria if not handled properly.

A. Temporary memory loss B. Neck pain C. Voice alteration D. Tingling of the scalp

Correct Answer is A

Explanation

ECT can cause temporary memory loss, particularly for events occurring around the time of the treatment. The client may experience difficulty remembering details of recent events or conversations. This effect is usually temporary and improves over time.

B. Neck pain is not a typical adverse reaction to ECT. The procedure itself does not involve manipulation or strain on the neck, and significant neck pain following ECT would be unusual. However, it is essential for the nurse to assess and address any discomfort or pain the client experiences after the procedure.
C. Voice alteration is not a known adverse reaction to ECT. ECT primarily affects the brain and does not directly impact the vocal cords or voice production.
D. Tingling of the scalp is not a common adverse reaction to ECT. During the procedure, the client receives a brief electrical stimulus, usually applied through electrodes placed on the scalp.
Sensations experienced during the procedure are typically related to the electrical stimulation and are transient.

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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?

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Correct Answer is D

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Correct Answer is A

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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?