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

Splinting the incision with a pillow when changing positions can provide support and help minimize discomfort and pain in clients who have undergone a cesarean birth. It can help reduce strain on the incision site and provide a sense of stability and comfort.
A. "You can apply counterpressure to your back with each position change" may be helpful for managing back pain, but it does not specifically address the client's request for nonpharmacological interventions to manage pain when changing positions after a cesarean birth.
C. "You should change positions as little as possible" is not an appropriate response as it does not address the client's need to manage pain when changing positions. Encouraging movement and position changes, along with appropriate support, can aid in recovery and prevent complications such as blood clots and respiratory issues.
D. "You should use patterned-paced breathing when changing positions" is not specifically related to managing pain when changing positions after a cesarean birth. While breathing techniques can be useful for pain management during labor and certain procedures, they may not be the most effective strategy for managing pain when changing positions post-cesarean.

A. "Sleep longer hours on the weekend." B. "Keep the television volume low while you are trying to fall asleep." C. "Establish a daily exercise routine." D. "Remain in bed until you fall asleep."

Correct Answer is C

Explanation

Regular physical exercise has been shown to promote better sleep. Engaging in daily exercise can help regulate the sleep-wake cycle, promote relaxation, reduce anxiety and stress, and increase overall sleep quality. It is important to note that exercise should ideally be done earlier in the day, at least a few hours before bedtime, as exercising too close to bedtime may actually have a stimulating effect and make it harder to fall asleep.
The other options listed are not the most appropriate recommendations for addressing difficulty in falling asleep:
1. "Sleep longer hours on the weekend." This suggestion may disrupt the client's sleep routine and can lead to inconsistent sleep patterns throughout the week, potentially making it more challenging to fall asleep on subsequent nights.
2. "Keep the television volume low while you are trying to fall asleep." It is generally recommended to create a sleep-friendly environment, which includes reducing external stimuli like noise, light, and electronic devices in the bedroom. However, watching television right before bedtime can interfere with sleep as the bright light and stimulating content can keep the mind awake.
3. "Remain in bed until you fall asleep." This recommendation may contribute to increased frustration and anxiety if the client is unable to fall asleep quickly. It is generally advised to practice good sleep hygiene, which includes getting out of bed if unable to fall asleep after a reasonable amount of time and engaging in a relaxing activity until feeling sleepy again.

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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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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?