3. A client with Alzheimer's disease has superficial skin breakdown related to functional incontinence. The correct nursing intervention includes:
3. A client with Alzheimer's disease has superficial skin breakdown related to functional incontinence. The correct nursing intervention includes:
. Inserting a continuous indwelling catheter per order.
. Assisting to the toilet and protecting bed with pads.
. Limiting oral fluid intake to 250 mL/day.
. Administering a loop diuretic, such as furosemide, as ordered.
Test-Taking Tip
Choose the option that supports normal functioning (toileting). Three of the choices alter intake or normal output.
Content Area: Geriatrics, Integumentary; Integrated Process: Nursing Process, Implementation; Cognitive Level: Comprehension; Client Need/Subneed: Physiological Integrity/Basic Care and Comfort/Elimination
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Answer 1 is incorrect because indwelling catheters are associated with a risk for infection, and should not be used as a nursing convenience. Answer 2 is correct because, in functional incontinence, as in Alzheimer's disease, the client is usually unable to perform self-care because of alteration in mental status. Assisting the client to use a toilet and cleaning after any incontinence are appropriate. Answer 3 is incorrect because this severe fluid restriction would dehydrate the client and is inappropriate. Answer 4 is incorrect because diuretics are appropriate for clients whose cardiorenal function is compromised. There is no evidence here to support use of this drug.