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.)
"Attempt to void every 2 hours."
"Perform Kegel exercises several times daily."
"Maintain a daily fluid intake of 1,000 to 1,200 mL/day."
"Take prescribed diuretics no later than 2000."
"Maintain optimal body weight for height."
Correct Answer : A,B,E
Rationale:
A. "Attempt to void every 2 hours.": Scheduled voiding helps reduce the likelihood of bladder overfilling and decreases episodes of leakage, especially in stress incontinence where physical pressure causes urine loss.
B. "Perform Kegel exercises several times daily.": Kegel exercises strengthen the pelvic floor muscles, which support the bladder and urethra. Regular practice improves muscle tone and helps control urine leakage during activities like coughing or sneezing.
C. "Maintain a daily fluid intake of 1,000 to 1,200 mL/day.": Limiting fluids excessively can lead to concentrated urine and bladder irritation, increasing urgency and risk of infection. A moderate, well-balanced intake closer to 1,500–2,000 mL/day is generally recommended.
D. "Take prescribed diuretics no later than 2000.": While relevant for fluid management, it's not a direct or primary instruction specifically for treating or managing stress incontinence itself. Diuretics increase urine production, which could potentially worsen incontinence.
E. "Maintain optimal body weight for height.": Excess weight increases abdominal pressure on the bladder, worsening stress incontinence. Achieving and maintaining a healthy weight can reduce symptoms and support pelvic muscle strength.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. "I will drink half of a cup of fruit juice when I feel shaky and weak.": Shakiness and weakness are early signs of low blood glucose, and consuming 15 grams of a fast-acting carbohydrate like ½ cup of fruit juice is an appropriate immediate response.
B. "I will soak my feet in water before applying lotion between my toes.": Diabetic clients should avoid soaking their feet due to the risk of skin maceration and infection. Lotion should not be applied between the toes, as this can promote fungal growth in a moist environment.
C. "I will skip a snack if I'm not hungry after lunch.": Skipping snacks can lead to hypoglycemia, especially if insulin has been administered. Even when not hungry, small carbohydrate intake may be necessary depending on the insulin regimen and activity level.
D. "I will only go without socks and shoes when I am in my home.": Diabetic clients should always wear protective footwear, even at home, to avoid undetected foot injuries that can lead to ulcers or infections due to impaired sensation and circulation.
Correct Answer is D
Explanation
Rationale:
A. "You can lift objects that weigh 15 pounds.": Clients recovering from retinal detachment repair should avoid lifting heavy objects, even as light as 15 pounds. Increased intraocular pressure from straining can compromise the surgical repair.
B. "Pick up items by bending at the waist.": Bending at the waist increases intraocular pressure and should be avoided postoperatively. Clients are advised to bend at the knees and keep their head upright to reduce pressure on the eye.
C. "Avoid reading for 3 days following surgery.": Reading is usually restricted only if it causes eye strain or requires eye movement that could interfere with healing. It is not routinely restricted for a set number of days unless otherwise specified by the surgeon.
D. "Take a stool softener daily.": Straining during bowel movements increases intra-abdominal and intraocular pressure. Stool softeners help prevent straining, making them a useful part of postoperative care after eye surgery to protect the surgical site.
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