A nurse working in a community clinic is talking with an older adult client who states that their life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development?

The correct answer is choice B: Empty the drainage bag when it is three-fourths full.

Choice A rationale:

Cleaning the perineal area at least once a day is important for maintaining hygiene, but it is not the most relevant action in this scenario. The focus here is on managing the urinary catheter and its drainage bag.

Choice B rationale:

Emptying the drainage bag when it is three-fourths full is the correct action. An indwelling urinary catheter requires regular drainage to prevent the risk of infection and blockages. Allowing the bag to become too full could lead to backflow and increase the likelihood of urinary tract infections.

Choice C rationale:

Flushing the catheter with sterile water daily is not typically part of routine catheter care. Catheter flushing might be done for specific medical reasons, but it is not a general guideline for indwelling catheters.

Choice D rationale:

Disconnecting the drainage bag when emptying and measuring urine is incorrect. Maintaining a closed system is crucial to prevent introducing bacteria into the urinary tract. Disconnecting the bag could increase the risk of infection.

The correct answer is choice B: "Support the client's feet with foot boots."

Choice A rationale:

Flexing the client's feet using pillows might not be sufficient to prevent foot drop. Foot drop is a condition where the client is unable to dorsiflex their foot, and using pillows alone may not provide adequate support to prevent this condition.

Choice B rationale:

Supporting the client's feet with foot boots is the most appropriate intervention to prevent foot drop due to immobility. Foot boots are specifically designed to hold the foot in a dorsiflexed position, preventing the calf muscles from tightening and causing foot drop.

Choice C rationale:

Placing a hand roll under the client's heels might offer some relief, but it's not the most effective intervention for preventing foot drop. Hand rolls are generally used to prevent footdrop by keeping the ankles in a neutral position, rather than solely supporting the heels.

Choice D rationale:

Removing ankle-foot orthotic devices at bedtime is not recommended if the client is at risk for developing foot drop. Ankle-foot orthotic devices are designed to provide continuous support to the feet and prevent muscle contractures. Removing them at bedtime could compromise the effectiveness of the intervention.