A nurse is planning care for a male client who is postoperative following a hernia repair. Which of the following actions should the nurse include in the plan?
Elevate the client's scrotum on a pillow.
Restrict fluids to 1,200 mL per day.
Place a warm pack on the incisional area.
Encourage the client to sit to void.
The Correct Answer is A
Rationale:
A. Elevate the client's scrotum on a pillow: After hernia repair, scrotal elevation helps reduce swelling and promote venous return, minimizing postoperative edema and discomfort. Supporting the scrotum with a pillow or rolled towel also decreases tension on the incision site, enhancing comfort and healing.
B. Restrict fluids to 1,200 mL per day: Fluid restriction is not indicated for clients following hernia repair unless there is a concurrent condition such as renal or cardiac impairment. Adequate hydration is essential to prevent constipation and promote tissue recovery after surgery.
C. Place a warm pack on the incisional area: Warm packs should be avoided immediately after surgery because they can increase local blood flow and risk of bleeding at the incision site. Cold packs may be used instead to reduce swelling and provide comfort.
D. Encourage the client to sit to void: Male clients are encouraged to stand when voiding to reduce intra-abdominal pressure on the surgical site. Sitting to void may increase pressure on the repaired area, potentially causing discomfort or strain on the incision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "Take your diuretic medication with your evening meal.": Taking diuretics in the evening can increase nocturia and exacerbate urinary incontinence. Diuretics are typically scheduled in the morning to minimize nighttime urination.
B. "Limit your fluid intake to 500 milliliters per day.": Severely restricting fluids can lead to dehydration and concentrated urine, which may irritate the bladder and worsen urge incontinence. Adequate hydration should be maintained while managing bladder habits.
C. "Plan to urinate every 3 hours while you are awake.": Scheduled voiding or bladder retraining involves establishing regular intervals for urination. Urinating every 2–3 hours helps the bladder gradually increase capacity and reduces episodes of urge incontinence by promoting control.
D. "Decrease your intake of cranberry juice.": Cranberry juice may acidify urine but is not a primary intervention for bladder retraining. Avoiding irritants like caffeine or alcohol is more relevant for managing urge incontinence.
Correct Answer is ["A","B","C"]
Explanation
Rationale:
A. A client who describes feeling disconnected from those around him following the hurricane: Emotional detachment or a sense of estrangement from others is a hallmark symptom of posttraumatic stress disorder (PTSD).
B. A client who describes having persistent feelings of anger about the hurricane: Ongoing irritability, anger, or emotional outbursts several months after a traumatic event may indicate unresolved trauma or hyperarousal, which are common features of PTSD.
C. A client who has frequent nightmares about the hurricane: Recurrent distressing dreams or flashbacks related to the traumatic event are hallmark re-experiencing symptoms of PTSD. Such nightmares suggest the trauma continues to affect the client’s sleep and mental health, justifying referral for further assessment.
D. A client who moved to an apartment located on higher ground than her previous home: Moving to a new location demonstrates adaptive coping and an effort to regain a sense of safety. This behavior does not indicate the presence of PTSD symptoms.
E. A client who expresses a realization that life will not return to the way it was before the hurricane: Acceptance and acknowledgment of change represent a healthy adjustment process. While grief or sadness may accompany this awareness, it reflects adaptation rather than pathological stress or trauma.
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