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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is c. I will eat foods high in potassium because the diuretics cause potassium loss.
Rationale for Choice A:
- Statement:"I should weigh myself daily and report any sudden weight loss or gain."
- Rationale:This statement is correct.It's crucial for patients with SIADH to monitor their weight daily as even slight fluctuations can signal fluid imbalances.Sudden weight gain can indicate fluid retention,while sudden weight loss might suggest dehydration.Both scenarios warrant medical attention.
Rationale for Choice B:
- Statement:"I need to limit my fluid intake to no more than 1 quart of liquids a day."
- Rationale:This statement is also correct.Fluid restriction is a cornerstone of SIADH management.By limiting fluid intake,patients can help prevent the buildup of excess fluid in the body,which can lead to complications such as hyponatremia (low sodium levels in the blood) and edema.
Rationale for Choice C:
- Statement:"I will eat foods high in potassium because the diuretics cause potassium loss."
- Rationale:This statement is incorrect.While some diuretics used in the treatment of SIADH can indeed cause potassium loss,this is not a universal side effect.Furthermore,increasing potassium intake without medical supervision can be dangerous,potentially leading to hyperkalemia (high potassium levels in the blood).It's essential for patients to consult with their healthcare providers for individualized guidance on potassium intake.
Rationale for Choice D:
- Statement:"I need to shop for foods that are low in sodium and avoid adding salt to foods."
- Rationale:This statement is correct.A low-sodium diet is often recommended for patients with SIADH to help manage fluid balance and prevent hyponatremia.Restricting sodium intake can reduce fluid retention and help maintain appropriate sodium levels in the blood.
Correct Answer is C
Explanation
The correct answer is choicec. The cobalamin injections will prevent me from becoming anemic.
Choice A rationale:
Cobalamin (B12) injections do not increase hydrochloric acid production in the stomach.Chronic atrophic gastritis often leads to decreased production of hydrochloric acid due to the loss of parietal cells, but B12 injections do not reverse this condition.
Choice B rationale:
The need for cobalamin injections is typically lifelong in patients with chronic atrophic gastritis because the condition leads to a permanent loss of intrinsic factor, which is necessary for B12 absorption. The injections are not just until the stomach heals.
Choice C rationale:
Chronic atrophic gastritis can lead to vitamin B12 deficiency due to the loss of intrinsic factor, which is essential for B12 absorption.This deficiency can cause pernicious anemia, and B12 injections are necessary to prevent this condition.
Choice D rationale:
While chronic atrophic gastritis does increase the risk of stomach cancer, B12 injections are not specifically aimed at reducing this risk.The primary purpose of B12 injections is to prevent anemia.
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