The nurse is bathing a client with dementia who has been cooperating throughout the process. As the nurse prepares to bathe the client's genitalia, the female client starts screaming, "No! Don't touch me there! Rape!"

Question

Which action by the nurse is the most appropriate?
1. Stop and assess the cause of the distress.
2. Explain that the client needs to be cleaned, but it will be done in a second.
3. Proceed with the bath but finish quickly.
4. Finish the bath without touching the genitalia.

Answer 1

Correct Answer: 1

The nurse's best course of action is to stop and assess for the cause of the distress. The nurse can adjust the approach to reduce the client's anxiety. It would not be healthy to avoid washing the genitals, especially if the client has experienced incontinence or leakage, but even without these concerns, the genitalia must be cleaned regularly to avoid tissue damage. Proceeding with the bath while the client screams is not ideal; a better strategy would be to encourage the client to wash her own genitalia with some guidance or assistance.