A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instructions should the nurse give the client?
“Take your diuretic medication with your evening meal."
"Decrease your intake of cranberry juice."
"Plan to urinate every 3 hours while you are awake"
“Limit your fluid intake to 500 milliliters per day."
The Correct Answer is C
A. “Take your diuretic medication with your evening meal." Taking diuretics in the evening can increase nighttime urination, worsening sleep disruption and incontinence. They should generally be taken in the morning to minimize nocturia.
B. "Decrease your intake of cranberry juice." Cranberry juice is often recommended to promote urinary tract health, though it doesn’t directly worsen urge incontinence. It is not necessary to avoid it unless advised by a provider for another reason.
C. "Plan to urinate every 3 hours while you are awake." Scheduled voiding at regular intervals is a key strategy in bladder retraining. It helps reduce urgency episodes and gradually increases bladder capacity and control over time.
D. “Limit your fluid intake to 500 milliliters per day." Severely limiting fluids can lead to dehydration, concentrated urine, and bladder irritation, potentially worsening incontinence. Adequate fluid intake should be maintained unless otherwise directed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client calls the office multiple times per day to speak with their provider. This behavior may indicate anxiety or dependence, but it does not reflect rationalization, which involves making excuses to justify behavior.
B. The client states, "I only act this way because my partner makes me so angry." This is a clear example of rationalization, where the client is attempting to justify unacceptable behavior by blaming it on someone else rather than taking personal responsibility.
C. The client does not listen to the nurse during a discussion about their diagnosis. This may indicate denial or avoidance, not rationalization. The client may be overwhelmed and unwilling to accept the diagnosis.
D. The client reports that they get upset with their family members for "no apparent reason." This may suggest emotional dysregulation or projection, but it lacks the clear element of excuse-making that defines rationalization.
Correct Answer is D
Explanation
A. Rubeola (measles). Rubeola is transmitted through airborne particles and requires airborne precautions, including the use of an N95 respirator and placement in a negative pressure room. Droplet precautions would not provide sufficient protection due to the small particle size and long-range transmission.
B. Varicella (chickenpox). Varicella requires both airborne and contact precautions because it spreads via airborne respiratory droplets and direct contact with lesions. A client with varicella must be isolated in a negative pressure room and healthcare workers should use full PPE.
C. Tuberculosis. Tuberculosis is caused by Mycobacterium tuberculosis and is spread through airborne droplet nuclei, which remain suspended in the air for extended periods. It requires airborne precautions, including an N95 respirator and isolation in a specialized room.
D. Pertussis (whooping cough). Pertussis is a highly contagious bacterial infection that spreads through large respiratory droplets during coughing or sneezing. Droplet precautions are required, which include wearing a surgical mask when within 3 feet of the client and practicing proper hand hygiene to prevent transmission.
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