Examkin

Question

Difficulty: EasyBasic Care and Comfort

A nurse is planning basic care for an older adult client who has limited mobility and is experiencing new-onset urinary incontinence. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

  1. Apply a moisture barrier cream to the perineal area after each incontinence episode.Answer
  2. B
    Delegate the initial evaluation of the client's skin integrity to the Unlicensed Assistive Personnel (UAP).
  3. C
    Reassure the client that sudden urinary incontinence is a normal, expected change of aging.
  4. D
    Keep the head of the bed completely flat during meals to reduce shear on the sacrum.
  5. Establish an individualized, scheduled toileting routine every 2 to 3 hours during waking hours.Answer

Answer

The correct interventions are applying a moisture barrier cream to the perineal area and establishing a scheduled toileting routine.
Applying moisture barrier creams and implementing scheduled toileting are foundational nursing interventions that promote comfort, protect skin integrity from urine exposure, and actively manage elimination needs in clients with limited mobility.

Step-by-Step Solution

1
Identify the primary basic care needs presented in the scenario.
The client has limited mobility and new-onset urinary incontinence, placing them at high risk for skin breakdown and loss of dignity.
Understanding the core deficits allows the nurse to prioritize appropriate hygiene and comfort measures.
2
Evaluate the independent nursing interventions that directly promote skin integrity and continence.
Using barrier creams and implementing a scheduled toileting routine are recognized best practices for basic care.
These actions proactively manage moisture and encourage normal elimination patterns.
3
Identify and eliminate contraindicated or unsafe actions in the remaining choices.
Delegating initial assessments, assuming new symptoms are normal aging, and laying flat during meals are eliminated.
These actions violate the nursing scope of practice, misinterpret pathological signs, and compromise airway safety.

Key Concept

Basic care measures for urinary incontinence and mobility deficits.
Rate this question

Topics

Basic Care and Comfort

More questions from this topic