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Difficulty: MediumBasic Care and Comfort

An older adult client is admitted to the medical unit with severe dehydration. The client is currently experiencing generalized muscle weakness, sudden-onset confusion, and frequent urinary incontinence. An intravenous (IV) fluid infusion is in progress. Which nursing intervention is the most appropriate to maintain this client's basic care and comfort?

  1. A
    Instructing the unlicensed assistive personnel (UAP) to evaluate the perineal skin for early signs of breakdown while changing the client's linens.
  2. B
    Reassuring the family members that the client's sudden onset of confusion is an expected physiological consequence of the normal aging process.
  3. Gently cleansing the perineal region with a pH-balanced cleanser and applying a moisture-barrier product following each incontinent episode.Answer
  4. D
    Initiating the use of soft bilateral wrist restraints to prevent the confused client from inadvertently dislodging the continuous IV infusion.

Answer

Gently cleansing the perineal region with a pH-balanced cleanser and applying a moisture-barrier product following each incontinent episode.
The application of pH-balanced cleansers and moisture barriers is a direct basic care and comfort measure that protects the skin from the maceration and chemical irritation caused by urinary incontinence. This prevents skin breakdown and promotes the client's overall physiological integrity and comfort.

Step-by-Step Solution

1
Analyze the client's clinical presentation, noting the combination of generalized weakness, new-onset confusion, and urinary incontinence.
The client is identified as being at high risk for impaired skin integrity due to excess moisture and an inability to independently reposition or manage personal hygiene.
Identifying physiological risks is the crucial first step in prioritizing basic care interventions.
2
Evaluate the proposed interventions against principles of basic care, comfort, safety, and scope of practice.
Skin protection emerges as the primary independent nursing intervention for comfort, while the other options violate safety protocols, misunderstand aging pathology, or involve improper delegation.
Appropriate nursing care must adhere to legal and ethical standards, including proper delegation and avoiding unnecessary restraints.

Key Concept

Skin Integrity and Hygiene Maintenance
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Topics

Basic Care and Comfort

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