A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?
Train the bladder by voiding every 5 hr.

Explanation

Choice A Reason:

A client receives burns from a heating pad is correct. Any injury or harm caused to a client due to a medical device or equipment should be documented in an incident report for evaluation and review to prevent future incidents.

Choice B Reason:

A client's visitor becomes dizzy and faints in the client's room is incorrect. While this event might prompt the nurse to provide immediate assistance and seek medical attention for the visitor, it doesn't typically fall under the purview of an incident report unless it results from an issue within the healthcare facility.

Choice C Reason:

A client becomes disoriented and falls out of bed is correct. Falls resulting in injury or harm to the client, especially due to disorientation, should be documented to assess potential preventive measures and ensure appropriate care.

Choice D Reason:

A client reports being dissatisfied with the temperature of the meals provided is incorrect. Client dissatisfaction with meal temperature is an important concern, but it's generally addressed through communication and service improvement rather than being documented in an incident report unless it poses a risk to the client's health (e.g., if the food was excessively hot, causing harm).

Choice A Reason:

Asking the client to state their room number is incorrect. A client with advanced dementia might not reliably remember or be able to state their room number, so this might not be a reliable method for identification.

Choice B Reason:

Having the client state their phone number is incorrect. Similar to the room number, relying on the client to state their phone number might not be feasible or reliable in cases of advanced dementia.

Choice C Reason:

Requesting an assistive personnel to identify the client is incorrect. While asking another staff member might seem practical, it might not ensure accurate identification, especially if the personnel is not directly involved in the client's care or isn't familiar enough with the client's identity due to frequent rotations or duties.

Choice D Reason:

Reviewing the client's photograph in the medical record is correct. Reviewing the client's photograph in the medical record is a reliable method to confirm the client's identity, especially in cases where the client might have difficulty providing other personal information due to advanced dementia.