The nurse is caring for a patient who has had a severe stroke and requires assistance to use the toilet. Which goal is the highest priority for this patient?
A) The patient will remain continent with no perineal skin breakdown.
B) The patient will state satisfaction with use of gait belt for toilet transfers.
C) The patient will regain ability to pull up clothing after using the toilet.
D) The patient will have privacy once properly positioned on the toilet.

Question

Quizplus · Accepted Answer

The highest priority goal for this patient is continence with no perineal skin breakdown to maintain skin integrity and self-esteem. Patient statements of satisfaction and the ability to pull up clothing are important but not the priority over preventing skin breakdown. Privacy is an intervention to be performed by the staff rather than a goal for the patient.

The Nurse Is Caring for a Patient Who Has Had