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

GERD can increase the risk of aspiration (inhalation of stomach contents into the lungs), which can cause respiratory issues, including abnormal breath sounds. In these cases, monitoring of breath sounds may be more appropriate than monitoring of bowel sounds.

Bowel sounds are not typically monitored for GERD patients as GERD is a condition that aﬀects the esophagus and the stomach, not the intestines. GERD is caused by the reﬂux of stomach contents into the esophagus, which can cause symptoms such as heartburn and regurgitation.

Abdominal girth is not routinely monitored for GERD patients as it is not typically related to the condition. GERD is a disorder that aﬀects the esophagus and stomach and does not typically cause significant changes in abdominal size or girth. In rare cases, GERD can be complicated by a condition known as a para oesophageal hernia, which can cause a visible bulge in the abdomen. In these cases, monitoring of abdominal size and shape may be necessary.

The apical pulse is not routinely monitored for GERD patients as it is not directly related to the condition. GERD is a disorder that aﬀects the digestive system, specifically the esophagus and stomach and does not typically have an impact on heart rate or rhythm.

A. The onset of diabetes and the associated cardiovascular risks can be delayed or prevented by weight loss and exercise. B. Although the fasting plasma glucose levels do not currently indicate diabetes, the glycosylated hemoglobin will be elevated. C. The high insulin levels associated with this syndrome damage the lining of blood vessels leading to vascular disease. D. The liver is producing excessive glucose, which will eventually exhaust the ability of the pancreas to produce insulin, and exercise will normalize glucose production.

Correct Answer is A

Explanation

This statement is correct. Impaired fasting glucose (IFG) is a condition in which the fasting blood glucose level is higher than normal but not high enough to be diagnosed as diabetes. However, people with IFG are at increased risk of developing type 2 diabetes and cardiovascular disease. Weight loss and exercise can help to prevent or delay the onset of diabetes and reduce the risk of cardiovascular disease.

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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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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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