A nurse is preparing a client for discharge home who is confused and incontinent after a stroke. Which instructions regarding bladder training will the nurse include in the teaching plan for the client's family?

"Oﬀer the client the commode or urinal every 2 hours."

"Decrease the client's oral ﬂuid intake to 1 L/day."

"Instruct the client to hold urine as long as possible to restore bladder tone."

"Use a Foley catheter at night to prevent accidents."

Answer and Explanation

The Correct Answer is A

The nurse will include the instruction "Oﬀer the client the commode or urinal every 2 hours" in the teaching plan for the client's family. This approach is known as timed voiding and can help the client re-establish a regular pattern of urination. Option "a" promotes frequent voiding, which helps

prevent accidents and promotes bladder health. Option "b" is not a recommended approach and can lead to dehydration, urinary tract infections, and other complications. Option "c" is also not recommended since holding urine for extended periods can lead to bladder distention and increase the risk of urinary tract infections. Option "d" is also not recommended since catheterization should only be considered in specific cases where other options have failed or are not feasible.

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Correct Answer is A

Explanation

The first step in the education plan should be to assess their understanding and perception of the disease. This will help the nurse to identify any misconceptions or knowledge gaps that the patient may have and tailor the education plan accordingly. Understanding the patient's perceptions will also help the nurse to establish a trusting relationship with the patient and increase their engagement in diabetes self-management.
Options b, c, and d are important components of the diabetes education plan, but they should be implemented after the initial assessment of the patient's perception and understanding of their diagnosis.

A. Excess ﬂuid volume related to intake greater than output. B. Risk for impaired skin integrity related to generalized edema. C. Activity intolerance related to muscle cramps and weakness. D. Insomnia related to waking at night to void.

Correct Answer is A

Explanation

Excess ﬂuid volume related to intake greater than output would be the most appropriate nursing diagnosis for a patient with symptoms of DI (diabetes insipidus). This condition results in excessive urine output and, as a consequence, can lead to dehydration and electrolyte imbalances. Therefore, monitoring and managing ﬂuid volume is a priority for patients with DI.

Risk for impaired skin integrity related to generalized edema is more commonly associated with conditions that cause ﬂuid retention such as heart failure, liver failure, or kidney disease, rather than DI.

Activity intolerance related to muscle cramps and weakness is a possible nursing diagnosis for patients with conditions that aﬀect muscle function, such as muscular dystrophy or multiple sclerosis, but not specifically for DI.

Insomnia related to waking at night to void is more commonly associated with urinary frequency or nocturia due to conditions such as urinary tract infections or benign prostatic hyperplasia, but not specifically for DI.

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A nurse is preparing a client for discharge home who is confused and incontinent after a stroke. Which instructions regarding bladder training will the nurse include in the teaching plan for the client's family?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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