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.
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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Related Questions
Correct Answer is B
Explanation
- "Your health care surrogate will make decisions on your behalf if you are unable": This statement is correct. A health care surrogate, also known as a health care proxy or durable power of attorney for health care, is an individual designated by the client to make medical decisions on their behalf if they become unable to make decisions for themselves. It is important for the client to choose someone they trust and who understands their values and wishes.
- "You should appoint a family member as your health care surrogate": This statement is a subjective recommendation and may not be applicable to all individuals. The decision of whom to appoint as a health care surrogate should be based on the client's personal preferences and the individual's ability to make informed decisions according to the client's wishes. While a family member is often chosen, it is not a requirement, and the client may choose a close friend, partner, or anyone else they trust to fulfill this role.
- "You will need an attorney to appoint a health care surrogate": This statement is not necessarily true. While involving an attorney can be helpful, it is not always required to appoint a health care surrogate. In many jurisdictions, a legally valid healthcare surrogate designation can be made through a simple document or form provided by the hospital or a local government office. It is important to check the specific legal requirements in the client's jurisdiction.
"Your health care surrogate will make decisions on your behalf if you are unable": This statement is correct. A health care surrogate, also known as a health care proxy or durable power of attorney for health care, is an individual designated by the client to make medical decisions on their behalf if they become unable to make decisions for themselves. It is important for the client to choose someone they trust and who understands their values and wishes.
"You will need an attorney to appoint a health care surrogate": This statement is not necessarily true. While involving an attorney can be helpful, it is not always required to appoint a health care surrogate. In many jurisdictions, a legally valid healthcare surrogate designation can be made through a simple document or form provided by the hospital or a local government office. It is important to check the specific legal requirements in the client's jurisdiction.
"You should appoint a family member as your health care surrogate": This statement is a subjective recommendation and may not be applicable to all individuals. The decision of whom to appoint as a health care surrogate should be based on the client's personal preferences and the individual's ability to make informed decisions according to the client's wishes. While a family member is often chosen, it is not a requirement, and the client may choose a close friend, partner, or anyone else they trust to fulfill this role.
"Once you have completed a living will, it cannot be changed": This statement is incorrect. A living will, which is a type of advanced directive, can be changed or revoked at any time by the client as long as they are competent to do so. It is important for the client to review and update their living will periodically to ensure that it reflects their current wishes regarding medical care and treatment.
Correct Answer is D
Explanation
Furosemide works by promoting diuresis, which helps to reduce fluid volume overload in heart failure. Increased urinary output indicates that the medication is effectively removing excess fluid from the body. This can help alleviate symptoms such as edema and fluid retention commonly associated with heart failure. Therefore, an increased urinary output is a positive response to furosemide therapy in this context.
Decreased BUN (blood urea nitrogen) levels and weight loss are also expected outcomes of diuretic therapy, further indicating the effectiveness of the medication. However, a decreased hemoglobin level is not directly related to the efficacy of furosemide and might be indicative of other factors such as anemia or bleeding, requiring further assessment and intervention.
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