An older adult client in a long-term care facility has dementia and begins to have frequent episodes of urinary incontinence. After the provider finds no medical cause for his incontinence, which of the following interventions should the nurse initiate to manage this behavior?
Remind the client to tell the nurse when he has to urinate
Use adult diapers to prevent frequent clothing changes.
Take the client to the bathroom on an every-2-hr schedule.
Request a prescription for an indwelling urinary catheter.
The Correct Answer is C
A. Remind the client to tell the nurse when he has to urinate.
Reminding the client may not be effective, as individuals with dementia may have difficulty expressing their needs or may forget to communicate when they need to use the bathroom. It relies on the client's ability to remember and communicate.
B. Use adult diapers to prevent frequent clothing changes.
While adult diapers can be part of a comprehensive plan for managing incontinence, they should not be the sole intervention. Relying solely on diapers does not address the underlying causes of incontinence and may not promote optimal dignity and quality of life.
C. Take the client to the bathroom on an every-2-hr schedule.
This is the correct choice. Taking the client to the bathroom on a regular schedule (timed voiding) is a proactive approach to managing urinary incontinence in individuals with dementia. It helps reduce the likelihood of accidents by ensuring regular opportunities for toileting.
D. Request a prescription for an indwelling urinary catheter.
Indwelling urinary catheters are generally not recommended for managing routine urinary incontinence due to the associated risks, including infection. Catheters should be used judiciously and based on medical necessity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Xerostomia
Xerostomia is dry mouth, a condition where the salivary glands do not produce enough saliva. It can have various causes, including medications, medical conditions, or dehydration. Xerostomia is not directly related to teeth grinding.
B. Halitosis
Halitosis is bad breath. While dental issues, including bruxism (teeth grinding), can contribute to bad breath, halitosis itself does not specifically describe teeth grinding.
C. Bruxism
Bruxism is the medical term for teeth grinding or clenching, especially during sleep. If a client suspects or reports grinding their teeth at night, it is appropriate to document and discuss the issue as bruxism. Bruxism can lead to dental problems, jaw pain, and headaches.
D. Sordes
Sordes refers to a collection of foul matter, such as debris or crusted material, around the mouth. It is not related to teeth grinding.
Correct Answer is C
Explanation
A. Keep the prosthesis in direct contact with the residual limb.
This statement is incorrect. Prosthetic care typically involves using a liner or sock between the residual limb and the prosthesis. This helps to provide cushioning, absorb sweat, and reduce friction, contributing to comfort and preventing skin irritation.
B. Apply a moisturizing lotion or oil to the stump daily.
Moisturizing the skin on the residual limb is generally advisable to prevent dryness and irritation. However, it's crucial to ensure that the skin is completely dry before attaching the prosthesis. Moisturizing can help maintain skin health and comfort.
C. Dry the prosthesis socket completely before applying it to the limb.
This statement is correct. Ensuring that the prosthesis socket is thoroughly dry before application is crucial to prevent skin irritation and ensure a secure fit. Moisture between the skin and the prosthesis can contribute to discomfort and skin-related issues.
D. Expect some skin irritation from the prosthesis.
While it is common to experience minor skin irritation initially as the individual adjusts to the prosthesis, persistent or severe irritation should be addressed. The goal is to achieve a proper fit and minimize skin-related problems through appropriate care and adjustments.
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