An older adult client residing in a long-term care facility has become disoriented and suddenly develops urinary incontinence. Which intervention should the nurse implement?

Obtain a clean, voided urine specimen for analysis.

Evaluate the client's response to bladder training efforts.

Place a protective undergarment on the client.

Encourage increased fluid intake for 24 hours.

Answer and Explanation

The Correct Answer is A

A.   Urinary incontinence in an older adult can be a symptom of various underlying conditions, such as urinary tract infections, dehydration, or cognitive impairment. Obtaining a urine specimen for analysis can help to identify the underlying cause of the incontinence and guide appropriate treatment.
B.   Bladder training is a technique used to improve bladder control and reduce incontinence. However, it's not appropriate to evaluate the client's response to bladder training efforts when they have suddenly become disoriented and developed incontinence. This suggests a potential underlying medical condition that needs to be addressed first.
C.   While protective undergarments can be helpful in managing incontinence, they do not address the underlying cause of the problem. It's important to identify and treat the underlying condition to improve the client's quality of life and prevent complications.
D.   While dehydration can sometimes contribute to incontinence, it's not appropriate to increase fluid intake in a client who has suddenly become disoriented. This could worsen their condition, especially if they have cognitive impairment or other underlying medical conditions.

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Correct Answer is B

Explanation

A. While it is important to support the UAP's efforts, simply encouraging them to continue without
assessing the method used may not ensure the safety of the client. The UAP’s approach to assisting the
client could potentially involve unsafe practices, especially given the client's significant vision loss.
B. Demonstrating safe ambulation techniques to the UAP ensures that the client is guided effectively and safely. For clients with significant vision loss, it is essential to use specific techniques, such as providing clear verbal cues, using a sighted guide method (e.g., having the client hold the guide's arm), and ensuring a clear and safe path.
C. This choice may be premature without evaluating the current situation. It assumes the UAP is providing unsafe assistance, but it does not provide a solution to how the UAP should assist the client in a more effective manner.
D. Allowing the client to ambulate independently, especially after significant vision loss, might not be safe. Clients who have recently lost their vision may require assistance to navigate their environment safely. While staying nearby can offer some level of safety, it is not sufficient if the client needs hands- on guidance and support to avoid hazards.

A. Notify the healthcare provider of the client's concerns. B. Ask an unlicensed assistive personnel to stay with the client. C. Obtain a bedside commode for the client to use. D. Place the bedpan within the reach of the client.

Correct Answer is C

Explanation

A. While notifying the healthcare provider may be necessary in some cases, it's not the most immediate or appropriate action in this situation. The nurse can address the client's concerns directly by providing a bedside commode.
B. While having a UAP available for assistance can be helpful, providing a bedside commode is a more practical and efficient solution.
C. A bedside commode can help prevent accidents and spills, which can be embarrassing and contribute to a negative experience. Offering a bedside commode demonstrates respect for the client's concerns and preferences, which can help to build trust and improve the overall care experience.
D. A bedpan may not be as comfortable or convenient for the client as a bedside commode, especially if they have mobility limitations.

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An older adult client residing in a long-term care facility has become disoriented and suddenly develops urinary incontinence. Which intervention should the nurse implement?

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