An older female resident of a long-term care facility is experiencing frequent episodes of urinary incontinence. Which intervention is best for the nurse to implement with this client?

Decrease time intervals between toileting assistance and encourage Kegel exercises.

Apply disposable undergarments and change frequently to prevent skin breakdown.

Limit fluid intake during the evening meal and throughout the evening hours until bedtime.

Offer emotional support and explain that urinary incontinence is a common occurrence among older women.

Answer and Explanation

The Correct Answer is A

A.   Decreasing the time intervals between toileting can help prevent accidents by ensuring that the resident has more frequent opportunities to use the bathroom. Encouraging Kegel exercises (pelvic floor exercises) can help strengthen the muscles responsible for controlling urination and may improve incontinence.
B.   Using disposable undergarments and changing them frequently can help manage incontinence and protect the skin from irritation and breakdown. However, this intervention primarily addresses the symptoms of incontinence rather than the underlying causes.
C.   Limiting fluid intake in the evening can reduce the likelihood of nocturia (nighttime urination) and may help in managing urinary incontinence. However, reducing fluid intake can also lead to dehydration and other health issues.
D.   Offering emotional support and reassurance is important for the resident’s mental well-being and can help reduce anxiety related to incontinence. Understanding that urinary incontinence is common among older adults can be comforting, but this approach alone does not address the practical management of the condition or contribute to improving urinary control.

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Correct Answer is C

Explanation

A. Knowing the consistency of the prescribed diet (e.g., pureed, mechanical soft, or regular) is important for planning the feeding process and ensuring that the diet meets the client's needs and restrictions. However, this information is secondary to assessing the client’s ability to safely chew and swallow.
B. While reviewing current medications is important for understanding potential drug interactions, side effects, or dietary restrictions, it is not the most immediate concern before feeding. Medications can influence appetite and digestion, but the priority is ensuring the client can safely handle the food.
C. This is the most critical information to obtain before feeding a debilitated client. Assessing the client's ability to chew and swallow helps prevent complications such as aspiration, choking, or aspiration pneumonia. The nurse should ensure that the client can safely manage the food given to them and that their swallowing mechanisms are functioning adequately.
D. While monitoring the respiratory rate and lung sounds is important for overall health assessment, it is not the immediate priority before starting a feeding session. However, it is important to monitor for signs of aspiration during and after feeding, as compromised swallowing can lead to aspiration pneumonia.

A. Compare the client's manifestations with the defining criteria of related problems. B. List the nursing actions that need to be implemented most immediately. C. Review the priority nursing problems included in the plan of care. D. Ensure that all treatments prescribed by the healthcare provider have been initiated.

Correct Answer is C

Explanation

A. This action involves assessing how the client’s current symptoms and manifestations align with the criteria of the nursing problems identified. By doing this, the nurse can ensure that the goals set are directly related to addressing these specific issues.
B. While prioritizing nursing actions is important for immediate care needs, listing these actions is more related to the implementation phase rather than the goal-setting phase. Goals are broader and focus on what outcomes are desired for the client, while nursing actions are specific steps taken to achieve those goals.
C. Reviewing the priority nursing problems helps in identifying the most urgent issues that need to be addressed. This review is essential for setting appropriate goals, as it ensures that the goals reflect the most pressing needs of the client.
D. Ensuring that prescribed treatments have been initiated is part of the implementation phase of care. While it is important for the overall management of the client’s health, this step does not directly involve goal setting.

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An older female resident of a long-term care facility is experiencing frequent episodes of urinary incontinence. Which intervention is best for the nurse to implement with this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?

Correct Answer is C

Explanation

When identifying the goals to be included in a client's plan of care, the nurse should take which action?

Correct Answer is C

Explanation

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