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

In this scenario, the nurse should take the action of obtaining the child's dietary history first. By gathering information about the toddler's current dietary intake, the nurse can assess the specific problems and challenges the child may be facing. This information will be crucial in developing an appropriate plan of care to address poor dietary intake.

Once the nurse has a clear understanding of the child's dietary habits, they can then proceed with other actions such as encouraging the family to be present during mealtimes, offering nutritious snacks, and providing instructions on praising the child when they eat. However, obtaining the dietary history will provide essential information for the nurse to make informed decisions and interventions.

A. "You can safely take this medication if you become pregnant." B. "You should expect to have blood work every 6 months while taking this medication." C. "You might experience swollen gums while taking this medication." D. “You can skip a dose of this medication if you are nauseated."

Correct Answer is C

Explanation

Phenytoin is known to cause gingival hyperplasia, which is characterized by swollen and enlarged gums. This side effect is more common in long-term use and may require dental care and regular oral hygiene practices.

Phenytoin is known to be associated with an increased risk of birth defects in babies born to women taking the medication during pregnancy. It is important for women of childbearing age to discuss the risks and benefits of phenytoin with their healthcare provider and use effective contraception to avoid pregnancy while taking the medication.

Phenytoin can affect liver function, so regular monitoring of liver enzymes and blood levels of the medication is necessary. The frequency of blood work may vary depending on the individual's specific situation, so it is important to follow the healthcare provider's instructions.

It is not advisable to skip a dose of phenytoin without consulting a healthcare provider. Abruptly stopping or missing doses of antiepileptic medications can lead to breakthrough seizures or other complications. Any changes in the medication regimen should be discussed with the healthcare provider.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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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?