A nurse is providing teaching to a client who has stress incontinence. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
"Perform Kegel exercises several times daily."
"Take prescribed diuretics no later than 2000."
"Maintain a daily fluid intake of 1,000 to 1,200 mL/day."
"Attempt to void every 2 hours."
"Maintain optimal body weight for height."
Correct Answer : A,D,E
Rationale:
A. "Perform Kegel exercises several times daily.": Kegel exercises strengthen pelvic floor muscles, improving bladder control and reducing stress incontinence episodes. Regular practice is essential for effectiveness.
B. "Take prescribed diuretics no later than 2000.": Limiting evening diuretic use helps reduce nighttime incontinence but does not address stress incontinence, which is triggered by increased intra-abdominal pressure, not fluid timing.
C. "Maintain a daily fluid intake of 1,000 to 1,200 mL/day.": Restricting fluids excessively can lead to concentrated urine and urinary tract irritation. Adequate hydration is important; fluid restriction is not recommended for stress incontinence.
D. "Attempt to void every 2 hours.": Scheduled voiding helps prevent bladder overfilling, reducing leakage episodes and improving bladder control. This is an effective behavioral strategy.
E. "Maintain optimal body weight for height.": Excess weight increases intra-abdominal pressure, which can worsen stress incontinence. Maintaining a healthy weight helps reduce strain on pelvic floor muscles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Serum albumin: Serum albumin is a key indicator of a client’s nutritional status, particularly protein intake and synthesis. Low albumin levels can reflect malnutrition, chronic illness, or liver dysfunction, while normal levels suggest adequate nutritional support and protein reserves.
B. Troponin level: Troponin is a cardiac biomarker used to diagnose myocardial injury or infarction. It is not related to nutrition and does not provide any information about the client’s dietary intake or protein status.
C. Serum sodium: Serum sodium reflects fluid and electrolyte balance rather than nutritional status. Abnormal sodium levels are typically associated with dehydration, fluid overload, or endocrine disorders, not with protein or calorie malnutrition.
D. Erythrocyte sedimentation rate: The erythrocyte sedimentation rate (ESR) is a nonspecific marker of inflammation and infection. It may rise with inflammatory conditions but does not provide direct information about a client’s nutritional health.
Correct Answer is B
Explanation
Rationale:
A. Skin warm and dry: Warm, dry skin indicates adequate circulation and fluid balance. In fluid overload, the skin is often cool and moist due to peripheral vasodilation and increased interstitial fluid. Therefore, this finding is not consistent with overhydration.
B. Respiratory rate 30/min: Tachypnea is a key indicator of fluid overload because excess fluid can accumulate in the lungs, leading to pulmonary congestion and decreased gas exchange. The body compensates by increasing the respiratory rate to improve oxygenation and remove excess carbon dioxide.
C. Heart rate 60/min: A normal heart rate suggests stable cardiovascular status. Fluid overload typically causes tachycardia as the heart works harder to manage increased circulatory volume, not a normal or bradycardic rate.
D. Tenting skin turgor: Tenting indicates dehydration, not fluid overload. In overhydration, the skin is usually taut and edematous due to excess interstitial fluid accumulation rather than loss of elasticity.
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