A nurse is contributing to the plan of care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following interventions should the nurse recommend?
Offer the client a bedpan every 2 hr.
Limit the client's daily fluid intake until he is no longer incontinent.
Request a prescription for an indwelling urinary catheter from the client's provider.
Ambulate the client to the bathroom every 30 min.
The Correct Answer is A
Choice A reason: This is the best intervention, because offering the client a bedpan every 2 hr can help prevent urinary retention, bladder distension, and infection, which can worsen the incontinence. It can also help maintain the client's dignity and comfort, and promote bladder retraining.
Choice B reason: This is an incorrect intervention, because limiting the client's daily fluid intake can cause dehydration, constipation, and urinary tract infection, which can aggravate the incontinence. The client should drink adequate fluids, unless the provider instructs otherwise.
Choice C reason: This is an incorrect intervention, because requesting a prescription for an indwelling urinary catheter is not recommended for a client who has occasional urinary incontinence. An indwelling urinary catheter can increase the risk of infection, trauma, and obstruction, and interfere with the bladder function. The nurse should use other methods of bladder management, such as intermittent catheterization, external catheter, or incontinence pads.
Choice D reason: This is an incorrect intervention, because ambulating the client to the bathroom every 30 min can be unrealistic, exhausting, and unsafe for a client who has hemiplegia, or paralysis of one side of the body, due to a stroke. The client may not be able to walk or transfer without assistance, and may fall or injure themselves. The nurse should assess the client's mobility and ability to use the bathroom, and provide appropriate aids and support.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is an important action, but not the first one. The nurse should obtain sample menus from the dietitian to give to the client after assessing the client's food preferences, needs, and goals. The sample menus should be individualized and tailored to the client's lifestyle, culture, and preferences.
Choice B reason: This is the first action, because the nurse should ask the client to identify the types of foods she prefers before providing any dietary teaching. This can help the nurse to determine the client's current eating habits, knowledge, and readiness to learn. It can also help the nurse to establish rapport and trust with the client, and to involve the client in the decision-making process.
Choice C reason: This is an important action, but not the first one. The nurse should identify the recommended range for the client's blood glucose level after assessing the client's food preferences, needs, and goals. The recommended range for the blood glucose level depends on the type, dose, and timing of the medication, the frequency and intensity of the exercise, and the carbohydrate intake of the client.
Choice D reason: This is an important action, but not the first one. The nurse should discuss long-term complications that can result from nonadherence to the dietary plan after assessing the client's food preferences, needs, and goals. The long-term complications of diabetes mellitus include cardiovascular disease, kidney disease, nerve damage, eye damage, and foot problems. The nurse should explain the benefits of following the dietary plan and the risks of not following it.
Correct Answer is A
Explanation
Choice A reason:Option Ais correct. NSAIDs like ibuprofen arecommonly prescribedfor SLE-related joint pain and inflammation, provided there are no contraindications (e.g., renal impairment). The client’s statement reflects appropriate understanding of symptom management.
Choice B reason: This is an incorrect statement, because SLE is a systemic autoimmune disease that can affect multiple organs and tissues, not just the skin. The client may experience symptoms such as rash, arthritis, nephritis, anemia, or pericarditis.
Choice C reason:Option Cis incorrect. SLE patients requirerigorous sun protection(SPF ≥30) to prevent UV-induced flares. SPF 15 is insufficient, indicating inadequate teaching.
Choice D reason: This is an incorrect statement, because a mild fever can indicate an infection or a flare-up of SLE, which can require medical intervention. The client should monitor the temperature and report any fever or signs of infection to the provider.
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