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 A

Explanation

A. This is a condition where the skin becomes hyperemic and hot after the application of heat. It's a sign of tissue damage and can lead to burns. Assessing for rebound phenomenon before applying a heating pad is crucial to prevent further injury.
B. While assessing range of motion can be helpful in determining the effectiveness of heat therapy, it's not the most important factor to consider before application.
C. Muscle strength and tone are not directly related to the risk of skin damage from heat therapy.
D. While neurosensory impairment can affect a client's ability to perceive heat and respond to pain, assessing for rebound phenomenon is a more direct way to evaluate the risk of skin damage.

A. Tilt the pelvis forwards and backwards. B. Turn the head to the right and left. C. Bend the arm by flexing the ulnar to the humerus. D. Extend the arm at the side and rotate in circles.

Correct Answer is C

Explanation

A. Tilting the pelvis forwards and backwards involves movements of the pelvic girdle, which is more related to the actions of the hip joints and lumbar spine, rather than hinge joints specifically. This action involves the pelvic tilt and is not an exercise for hinge joints like the elbow or knee.
B. Turning the head to the right and left involves rotation of the cervical spine and is associated with pivot joints rather than hinge joints. This action does not involve flexion and extension typical of hinge joints, which are primarily the elbow and knee.
C. This action involves bending the arm at the elbow joint, which is a classic example of a hinge joint. The elbow allows for flexion (bending) and extension (straightening) movements, making it a key example of a hinge joint. This is the correct action for exercising hinge joints.
D. Extending the arm and rotating in circles involves movements of the shoulder joint, which is a ball- and-socket joint, not a hinge joint. The shoulder joint allows for a wide range of movements including circumduction, which is different from the simple flexion and extension movements of hinge joints.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is A

Explanation

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

Correct Answer is C

Explanation

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