A nurse is implementing a bladder-training program for a client. For which of the following actions by the assistive personnel (AP) who is helping with the client's care should the nurse intervene?
Encourages oral fluid intake during waking hours
Assists the client to the bathroom every 2 hr
Offers the opportunity to urinate 15 min prior to bathing
Instructs the client to urinate whenever the urge occurs
The Correct Answer is D
Choice A reason: Encourages oral fluid intake during waking hours is not an action that the nurse should intervene. Encouraging oral fluid intake during waking hours is a part of a bladder-training program, as it helps to maintain adequate hydration and prevent urinary tract infections. The nurse should instruct the AP to limit the client's fluid intake before bedtime, as it may cause nocturia and disrupt the bladder-training schedule.
Choice B reason: Assists the client to the bathroom every 2 hr is not an action that the nurse should intervene. Assisting the client to the bathroom every 2 hr is a part of a bladder-training program, as it helps to establish a regular pattern of voiding and reduce the risk of incontinence. The nurse should instruct the AP to gradually increase the interval between bathroom visits, as the client's bladder capacity and control improve.
Choice C reason: Offers the opportunity to urinate 15 min prior to bathing is not an action that the nurse should intervene. Offering the opportunity to urinate 15 min prior to bathing is a part of a bladder-training program, as it helps to prevent the stimulation of the micturition reflex by warm water and reduce the risk of accidental voiding. The nurse should instruct the AP to avoid giving the client diuretics, caffeine, or alcohol, as they may increase the urine output and frequency.
Choice D reason: Instructs the client to urinate whenever the urge occurs is an action that the nurse should intervene. Instructing the client to urinate whenever the urge occurs is not a part of a bladder-training program, as it does not help to improve the bladder function and may worsen the urge incontinence. The nurse should instruct the AP to teach the client some techniques to suppress the urge, such as pelvic floor exercises, deep breathing, or distraction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Caffeinated beverages can cause diarrhea by stimulating the intestinal motility and increasing the fluid loss. They can also irritate the lining of the stomach and intestines.
Choice B reason: Low-fiber cereal is not likely to cause diarrhea. Fiber helps to bulk up the stool and regulate the bowel movements. Low-fiber foods are often recommended for clients with diarrhea to reduce intestinal activity.
Choice C reason: White rice is not likely to cause diarrhea. It is a bland and starchy food that can help to bind the stool and reduce fluid loss. White rice is often part of the BRAT diet (bananas, rice, applesauce, toast) that is suggested for clients with diarrhea.
Choice D reason: Ripe bananas are not likely to cause diarrhea. They are rich in potassium, which can help to replenish the electrolytes lost due to diarrhea. They also contain pectin, a soluble fiber that can help to firm up the stool.
Correct Answer is B
Explanation
The correct answer is b. Decreased deep tendon reflexes.
Choice A: Wheezing
Reason: Wheezing is typically associated with respiratory conditions such as asthma, chronic obstructive pulmonary disease (COPD), or allergic reactions. It is not a common manifestation of hyperkalemia. Hyperkalemia primarily affects the muscular and cardiovascular systems rather than the respiratory system.
Choice B: Decreased deep tendon reflexes
Reason: Hyperkalemia can cause neuromuscular symptoms, including muscle weakness and decreased deep tendon reflexes. High potassium levels interfere with the normal function of muscle cells and nerves, leading to these symptoms. This is a direct result of the altered action potentials in neurons caused by elevated potassium levels.
Choice C: Hypoactive bowel sounds
Reason: Hypoactive bowel sounds are generally associated with conditions that cause decreased gastrointestinal motility, such as ileus or bowel obstruction. While hyperkalemia can affect muscle function, it is more likely to cause hyperactive bowel sounds due to increased gastrointestinal motility rather than hypoactive sounds.
Choice D: Cerebral edema
Reason: Cerebral edema is swelling of the brain and is not a typical manifestation of hyperkalemia. It is more commonly associated with conditions such as traumatic brain injury, stroke, or severe infections. Hyperkalemia primarily affects the heart and muscles.
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