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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Related Questions
Correct Answer is D
Explanation
Choice A reason: This is an important action, but not the first one. The nurse should first address the client's comfort and inflammation before teaching them how to use the eye drops.
Choice B reason:Option B (warm compresses)is a key intervention for blepharitis to improve meibomian gland function and reduce crusting. However, assessment (Option D) must precede treatment to ensure no contraindications (e.g., corneal abrasion) and tailor care appropriately.
Choice C reason: This is a helpful action, but not the first one. The nurse should first apply warm compresses to the affected eye, and then dim the lights to reduce the sensitivity and pain.
Choice D reason:Thefirst stepin the nursing process isassessment. Even with a diagnosis of blepharitis, the nurse mustinspect the eyesto evaluate the current severity, presence of drainage (e.g., purulent vs. serous), redness, or signs of secondary infection (e.g., bacterial involvement). This informs subsequent interventions.
Correct Answer is D
Explanation
Choice A reason: This is an incorrect purpose, because raising the bed linens off the client's feet to prevent plantar flexion is not related to the use of an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and aligned. Raising the bed linens off the client's feet can be achieved by using a foot cradle or a bed frame.
Choice B reason: This is an incorrect purpose, because keeping the client's heels off the bed to prevent pressure ulcers is not related to the use of an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and aligned. Keeping the client's heels off the bed can be achieved by using a heel protector or a pillow under the lower legs.
Choice C reason: This is an incorrect purpose, because positioning the client off the operative site while in bed is not related to the use of an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and aligned. Positioning the client off the operative site can be achieved by using a trochanter roll or a pillow under the hip.
Choice D reason: This is the correct purpose, because preventing dislocation of the hip during position changes or movement is the main reason for using an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and
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