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 B
Explanation
Rationale:
A. Cheyne-Stokes respirations: This irregular breathing pattern is common in clients nearing end of life due to neurologic decline. It is not a direct indicator of pain and does not necessarily require pain medication unless associated with distress.
B. Restlessness: Restlessness in a palliative care client often signals unrelieved pain, discomfort, or anxiety. It is a nonverbal cue frequently observed in clients unable to communicate pain and should prompt consideration of analgesia.
C. Mottled skin: Mottling is a sign of reduced perfusion and impending death. It reflects circulatory changes but does not directly indicate pain or warrant pain medication unless accompanied by other signs of distress.
D. Constricted pupils: Pupil constriction may result from certain medications (e.g., opioids) or brainstem pressure but is not a reliable sign of pain. It does not, by itself, indicate a need for analgesic intervention.
Correct Answer is D
Explanation
Rationale:
A. "Every so often, I think about whether or not to have this surgery.": This statement suggests the client is still ambivalent or uncertain, which means informed consent has not yet been fully achieved. Clients must be sure and fully informed before agreeing to proceed.
B. "I will talk with the doctor about my surgery when I get into the operating room.": Informed consent must be obtained well before the procedure begins. Waiting until the operating room is inappropriate, as the client may be under stress or sedation.
C. "Can you tell me more about the surgery I am having?": This indicates the client lacks essential information about the procedure. Informed consent requires that the client already understand the nature, risks, benefits, and alternatives before signing.
D. "Signing this form indicates that I give my permission for the surgery, right?": This reflects an understanding that the consent form gives legal authorization for the procedure. It shows the client knows their signature confirms informed agreement to the surgery.
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