A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?
Train the bladder by voiding every 5 hr.
Training the bladder by voiding every 5 hr.
Applying adult diapers at bedtime is incorrect
Performing pelvic-muscle exercises is correct.
Drinking citrus juice with meals is incorrect
The Correct Answer is C
Training the bladder by voiding every 5 hr. is incorrect. For individuals experiencing urinary incontinence, scheduled voiding at regular intervals might be a part of the management plan. However, the specific interval of every 5 hours might not suit everyone, as it depends on individual bladder capacity and function. Scheduled voiding should be tailored to the individual's needs and not solely based on a fixed time frame.
Choice B Reason:
Applying adult diapers at bedtime is incorrect. While using protective garments like adult diapers may manage urinary incontinence during sleep, it doesn't address the underlying issue or provide a solution to improve the condition.
Choice C Reason:
Performing pelvic-muscle exercises is correct. Pelvic floor muscle exercises, also known as Kegel exercises, can help strengthen the muscles that support the bladder and control urine flow. This can potentially improve urinary incontinence by enhancing bladder control.
Choice D Reason:
Drinking citrus juice with meals is incorrect. Citrus juices can irritate the bladder and potentially exacerbate urinary incontinence for some individuals. Advising the consumption of citrus juice might not be beneficial and could worsen symptoms in certain cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
1. Unlock and remove the inner cannula (Step C). This is the initial step because it allows access to the inner cannula for cleaning. Removing it enables further cleaning of the inner cannula and ensures proper hygiene of the tracheostomy.
2. Scrub the inside and outside of the inner cannula with a small brush (Step D). Once the inner cannula is removed, it should be cleaned thoroughly to remove any secretions or debris. Scrubbing with a small brush helps in effectively cleaning both the inside and outside surfaces.
3. Wipe the inside of the inner cannula with a folded pipe cleaner (Step E). Using a pipe cleaner helps to reach areas that a brush might not access easily. It further ensures the removal of any remaining secretions or buildup inside the inner cannula.
4. Cleanse the stoma site with 0.9% sodium chloride solution (Step B). After addressing the inner cannula, the nurse moves to clean the stoma site to prevent infection or irritation. This step ensures the area around the tracheostomy is clean and free from contaminants.
5.Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin (Step A). Lastly, preparing the sterile basin with the saline solution should be done at the start to ensure it's ready for use during the cleaning process. This solution will be utilized for cleaning the stoma site in step B and may also be needed for moistening the brush or pipe cleaner during steps D and E.
Correct Answer is B
Explanation
Choice A Reason:
"I'm sure it's nothing serious and their appetite will return soon." Is incorrect. This response dismisses the concern without addressing the underlying issue. It might overlook potential reasons for the lack of appetite and could lead to neglecting a serious problem.
Given the concern about the client not eating, the most appropriate response for the nurse to make would be:
Choice B Reason:
"Tell me more about what happens at mealtime." Is correct. This response encourages the child to share specific details about the mealtime routine, any challenges, or reasons behind the lack of eating. It allows the nurse to gather more information, identify potential issues, and offer appropriate guidance or interventions. Understanding the context surrounding the eating habits can help determine the best approach to address the situation effectively.
Choice C Reason:
"Why do you think they're not eating?" is incorrect. While it encourages discussion, this response puts the responsibility on the child to provide explanations that they might not fully understand or be equipped to articulate. It's essential for the nurse to gather information but in a more supportive and guiding manner.
Choice D Reason:
"They may need a feeding tube." Is incorrect. Jumping to a conclusion about a feeding tube without gathering more information or exploring other possibilities could alarm the child unnecessarily. This response could also create unnecessary worry for the child and the family without assessing the situation comprehensively.
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