A nurse is teaching a client about bladder retraining for incontinence. Which of the following instructions should the nurse include in the teaching?

"Practice pelvic-floor exercises regularly."

"Wear a pair of disposable briefs at bedtime."

"Limit oral fluid intake to 1,000 milliliters per day."

"Drink 8 ounces of citrus juice per day."

Answer and Explanation

The Correct Answer is A

A) "Practice pelvic-floor exercises regularly.": This instruction is essential for bladder retraining. Pelvic-floor exercises, such as Kegel exercises, strengthen the muscles that support the bladder and can help improve control over incontinence.

B) "Wear a pair of disposable briefs at bedtime.": While using disposable briefs can provide comfort and protection, this approach does not contribute to bladder retraining. It may inadvertently allow the client to rely on them instead of focusing on improving bladder control.

C) "Limit oral fluid intake to 1,000 milliliters per day.": Limiting fluid intake is generally not recommended, as it can lead to concentrated urine and potential bladder irritation. Adequate hydration is important for overall health and can help maintain normal bladder function.

D) "Drink 8 ounces of citrus juice per day.": Citrus juices can irritate the bladder in some individuals, leading to increased urgency and frequency. It’s usually advisable to avoid such irritants during bladder retraining, making this instruction less appropriate.

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Correct Answer is B

Explanation

A) Exaggerated curvature of the sacrum: This is not a specific indicator of scoliosis. Scoliosis primarily involves lateral curvature of the spine, not an exaggerated curvature of the sacrum.

B) Uneven shoulder and pelvic heights: This is the correct answer. Scoliosis is characterized by an abnormal lateral curvature of the spine, which can lead to uneven shoulder and pelvic heights. This is a common clinical manifestation that nurses look for during screenings.

C) Mild pain in the hip region: While pain can sometimes accompany scoliosis, it is not a definitive clinical manifestation of the condition itself and is not typically used as an indicator during screenings.

D) Limited range-of-motion of the hips: Limited hip motion may occur due to other conditions but is not a primary sign of scoliosis. The assessment of scoliosis focuses more on spinal alignment and symmetry rather than hip mobility.

A. A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities B. A client who has Clostridium difficile and a temperature of 38.6° C (101.5° F) C. A client who has left shoulder pain and S-T elevation on a 12-lead ECG D. A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10

Correct Answer is C

Explanation

A) A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities: While this client requires assessment, their condition is not immediately life-threatening. Orthostatic hypotension and edema need to be evaluated, but they are not acute emergencies.

B) A client who has Clostridium difficile and a temperature of 38.6° C (101.5° F): This client needs attention due to the infection and fever, but it is not as critical as the potential cardiac event presented in option C.

C) A client who has left shoulder pain and S-T elevation on a 12-lead ECG: This client is exhibiting signs that may indicate an acute myocardial infarction (heart attack). S-T elevation on an ECG is a significant finding and suggests that this client could be experiencing a serious cardiac event, making it the priority for assessment.

D) A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10: While this client is in pain and requires care, the priority in emergency situations is often given to conditions that are life-threatening, such as those related to cardiac function. Therefore, this client can be assessed after addressing the potential cardiac emergency.

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A nurse is teaching a client about bladder retraining for incontinence. Which of the following instructions should the nurse include in the teaching?

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