A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care?
Request a prescription for an indwelling urinary catheter.
Arrange for an alternating pressure mattress.
Apply cornstarch to the client's skin.
Reposition the client every 4 hours.
The Correct Answer is B
An alternating pressure mattress can help prevent skin breakdown in a client who is immobile by redistributing pressure and reducing the risk of pressure ulcers. This is an appropriate action for the nurse to include in the plan of care for a client who is immobile and has urinary incontinence.
a. An indwelling urinary catheter can increase the risk of infection and should only be used when other methods of managing urinary incontinence are not effective.
c. Cornstarch can absorb moisture and help keep the skin dry, but it is not recommended for use on broken skin or in areas where there is a risk of fungal infection.
d. Repositioning the client every 4 hours may not be frequent enough to prevent skin breakdown. The client should be repositioned at least every 2 hours to reduce the risk of pressure ulcers.
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Related Questions
Correct Answer is D
Explanation
A. Complete the bath even if the client is in distress. – Forcing the bath can increase agitation and damage trust. If the client becomes distressed, pause, reassure, and try again later.
B. Allow the client to select the temperature of the bath water. – Clients with dementia may have impaired sensory perception, increasing the risk of burns or discomfort. The nurse should check the water temperature to ensure safety.
C. Give detailed instructions for the client to follow. – Clients with dementia may struggle to process multiple steps, leading to frustration. Instead, use simple, one-step instructions and gentle guidance.
D. Use distractions when bathing the client.Clients with dementia may experience anxiety, agitation, or distress during bathing. Using distractions, such as playing soothing music, talking about familiar topics, or providing a comforting touch, can help make the experience less stressful and more cooperative.
Correct Answer is C
Explanation
Tightening the abdominal muscles prior to moving helps to stabilize the spine and prevent back strain. This is an important technique for caregivers to use when assisting a client who is immobile and requires repositioning in bed.
a. Twisting at the waist while pulling the draw sheet can cause strain on the back muscles and should be avoided.
b. Keeping the legs straight does not provide more power in the lift and can also cause strain on the back muscles.
d. Placing the bed in the lowest position does not necessarily prevent back strain and is not related to the proper technique for repositioning a client in bed.
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