A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first?
Determine the client's pattern for voiding
Discourage intake of carbonated beverages.
Assist the client with relaxation techniques.
Offer toileting opportunities every 1 to 2 hr.
The Correct Answer is A
Explanation: The first step in bladder training is to assess the client's baseline bladder function and identify factors that may affect it, such as fluid intake, medications, or mobility issues. The other interventions are part of bladder training but should be implemented after assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Limiting the number of choices for the client who has Alzheimer's disease can help reduce confusion and frustration and promote independence and dignity. Using written signs to assist the client with locating the bathroom may not be helpful, as the client may have difficulty reading or remembering what they mean. Using confrontation to manage the client's behavior can increase agitation and aggression and worsen cognitive decline. Providing a stimulating environment for the client can also overwhelm and overstimulate them and cause sensory overload.
Correct Answer is D
Explanation
Choice A reason:
The face is incorrect: Facial skin colour can vary for many reasons, but it may not be the best indicator of jaundice in individuals with dark skin.
Choice B reason
Shoulders is incorrect: The shoulders are not typically indicative of jaundice.
Choice C reason:
Palm of the hands is incorrect: While the palm of the hands can sometimes show yellowing in cases of jaundice, it is less reliable than observing the sclera.
Choice D reason:
Sclera is the best location. In individuals with darker skin tones, yellowish discoloration of the skin due to jaundice can be more challenging to detect. However, the sclera of the eyes can still show noticeable yellowing, making it a reliable location for assessing jaundice in individuals with both light and dark skin.
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