A nurse is caring for a client who has urolithiasis. Which of the following actions should the nurse take?

Implement NPO status.

Place the client on bedrest.

Monitor the client's liver function.

Strain the client's urine.

Answer and Explanation

The Correct Answer is D

A. Implement NPO status: Clients with urolithiasis typically do not require NPO status unless they are scheduled for surgery or a procedure. Restricting oral intake unnecessarily can lead to dehydration, which may worsen stone formation or impede stone passage.

B. Place the client on bedrest: Ambulation is encouraged for clients with urolithiasis to promote urinary flow and facilitate passage of stones. Bedrest is generally not indicated unless there are complications, so restricting mobility could hinder stone expulsion.

C. Monitor the client's liver function: Liver function tests are not routinely affected by urolithiasis. Monitoring liver enzymes is unnecessary unless there is a separate hepatic condition or if the client is on medications that affect the liver.

D. Strain the client's urine: Straining urine allows for collection of passed stones, which can then be analyzed to determine stone composition. This information guides dietary recommendations, pharmacologic interventions, and prevention strategies for future stone formation.

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Correct Answer is B

Explanation

A. The client spends most of their day sleeping: Excessive sleep is more characteristic of depressive episodes in bipolar disorder. While fatigue can contribute to risk in some contexts, it does not directly indicate increased injury risk from manic behaviors.

B. The client is easily distracted by external stimuli: Distractibility is a hallmark of mania and can lead to impulsive or unsafe actions, such as leaving dangerous objects within reach, wandering, or starting multiple activities at once. This significantly increases the client’s risk for injury.

C. The client withdraws from group activities: Social withdrawal is more associated with depressive states. While it may affect engagement or mood, it does not inherently increase risk for injury due to manic behavior.

D. The client will only eat finger foods: Preferring finger foods may indicate impulsivity or hyperactivity but does not directly correlate with a substantial risk for injury. Safety risks are more closely tied to distractibility, poor judgment, and impulsive actions during mania.

A. "I can have mustard on my sandwiches." B. "I can season foods with celery salt." C. "I can eat frozen juice bar for dessert." D. "I can drink vegetable juice with my meals."

Correct Answer is C

Explanation

A. "I can have mustard on my sandwiches.": Mustard is high in sodium and can contribute significantly to daily sodium intake, which is contraindicated for clients with cardiomyopathy who need to limit sodium to reduce fluid retention and cardiac workload.

B. "I can season foods with celery salt.": Celery salt contains sodium and is not an appropriate seasoning for clients on a low-sodium diet. Using it can exacerbate fluid retention, hypertension, and worsening heart failure symptoms.

C. "I can eat frozen juice bar for dessert.": Many frozen juice bars are low in sodium and suitable for a heart-healthy, low-sodium diet. Choosing these types of snacks helps the client manage fluid balance and cardiac workload effectively.

D. "I can drink vegetable juice with my meals.": Most commercial vegetable juices are very high in sodium, making them inappropriate for clients who need to restrict sodium intake. Consuming these can lead to fluid retention and increased cardiac strain.

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A nurse is caring for a client who has urolithiasis. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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