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A nurse is caring for a female client who requires bed rest and reports difficulty urinating into a bedpan.
Which of the following actions should the nurse take?

A.

Turn on the faucets in the client's sink.

B.

Tell the client to gently stroke her lower abdomen.

C.

Instruct the client to lean slightly backward.

D.

Pour cool water over the client's perineum.

Answer and Explanation

The Correct Answer is B

Choice B rationale:

Instructing the client to gently stroke her lower abdomen is the appropriate action in this situation. Gentle stroking or tapping on the lower abdomen can stimulate the bladder reflex and promote urination. This technique can help clients who have difficulty voiding, especially when using a bedpan. It encourages relaxation of the pelvic muscles, making it easier for the client to urinate.

Choice A rationale:

Turning on the faucets in the client's sink is not a recommended action for promoting urination. While the sound of running water can sometimes trigger the need to urinate, it may not be effective for every individual. Moreover, this action may not be practical or feasible in all healthcare settings.

Choice C rationale:

Instructing the client to lean slightly backward is not an appropriate action for promoting urination. Leaning backward can put pressure on the bladder, which may make it more challenging for the client to urinate. Encouraging relaxation and using techniques like gentle abdominal stroking are more effective in this situation.

Choice D rationale:

Pouring cool water over the client's perineum is not a recommended action for promoting urination. While some individuals find warm water soothing and relaxing, pouring cold water may cause discomfort and stress, making it even more difficult for the client to urinate. Gentle stimulation and relaxation techniques are generally more effective.


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Related Questions

Correct Answer is C

Explanation

How does this make you feel?

  • A. Saying "I'm sure your family does not want you to die" is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's assumption on the client. This option is incorrect.
  • B. Asking "Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, and may make the client feel defensive or ashamed. This option is incorrect.
  • C. Asking "How does this make you feel?" is a therapeutic response, as it encourages the client to express their emotions and shows empathy and interest from the nurse. This option is correct.
  • D. Saying "You should talk to your family about your feelings" is not a therapeutic response, as it implies that the client is responsible for resolving their family issues and may increase their guilt or anxiety. This option is incorrect.

Correct Answer is A

Explanation

- A. This choice is correct because a child who has autism spectrum disorder often exhibits strict adherence to routines and rituals, and may become distressed or agitated when there are changes or disruptions to their usual patterns.

- B. This choice is incorrect because difficulty paying attention to tasks is not a specific manifestation of autism spectrum disorder, but rather a common symptom of attentiondeficit/hyperactivity disorder (ADHD). A child who has autism spectrum disorder may have difficulty focusing on tasks that are not of interest to them, but may also show intense concentration on tasks that are of interest to them.

- C. This choice is incorrect because disobedience to authority figures is not a specific manifestation of autism spectrum disorder, but rather a common behavior problem in children and adolescents. A child who has autism spectrum disorder may have difficulty understanding social cues and expectations, but may also show compliance and cooperation when given clear instructions and positive reinforcement.

- D. This choice is incorrect because excessive anxiety when separated from parents is not a specific manifestation of autism spectrum disorder, but rather a common symptom of separation anxiety disorder. A child who has autism spectrum disorder may have difficulty forming attachments and expressing emotions, but may also show affection and attachment to familiar people.

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