A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

Evaluate the effectiveness of this measure to stimulate client voiding.

Recommend a complete bath to cleanse the perineal area more fully.

Suggest contacting the healthcare provider for a prescription for catheter insertion.

Instruct the PN that this technique promotes infection in elderly females.

Answer and Explanation

The Correct Answer is A

Choice A reason: Pouring warm water over the perineal area can stimulate the micturition reflex, which may help the client void. It is a non-invasive, first-line intervention to promote natural voiding in clients with urinary incontinence. The nurse should evaluate its effectiveness as it can be a simple yet effective method to assist the client.

Choice B reason: While recommending a complete bath may help maintain hygiene, it does not directly address the immediate need to stimulate voiding. The nurse's priority is to manage the incontinence issue effectively and a bath can be considered after addressing the client's immediate needs.

Choice C reason: Suggesting catheter insertion may be premature without first attempting less invasive measures. Catheterization carries risks such as infection and should be considered only when other interventions are ineffective or not feasible.

Choice D reason: There is no evidence to suggest that pouring warm water over the perineal area promotes infection in elderly females. In fact, proper perineal care is essential in preventing infections, especially in clients with incontinence.

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Correct Answer is C

Explanation

Choice A reason: Right lower abdominal pain is not typically associated with Wernicke's syndrome and would likely indicate a different issue.

Choice B reason: Peripheral neuropathy can be a symptom of Wernicke's syndrome, but it is not as central to the condition as confusion, which is a hallmark sign.

Choice C reason: Confusion is a primary symptom of Wernicke's syndrome and should be used in planning the client's care, as it indicates acute encephalopathy and the need for immediate treatment with thiamine.

Choice D reason: Depression may be present in clients with Wernicke's syndrome, but it is not a primary assessment finding used to plan care for the acute stage of the condition.

A. Learned coping skills B. Psychological assessment C. Unstained weight loss D. Recovery close to hospital E. Recent weight loss F. Client's age G. Family support

Correct Answer is ["A","B","D","E","G"]

Explanation

Choice A reason: Learned coping skills are essential for managing the psychological aspects of obesity and the lifestyle changes required after bariatric surgery. The patient’s engagement with a psychologist and learning coping techniques can help her deal with postoperative stress and maintain the lifestyle modifications necessary for long-term success.
Choice B reason: A psychological assessment helps in understanding the patient’s readiness for surgery and ability to adhere to the postoperative regimen. It can identify any psychological barriers to weight loss and ensure that the patient is mentally prepared for the changes ahead.
Choice C reason: The term “unstained weight loss” seems to be a typographical error, possibly intending to mean “sustained weight loss.” However, sustained weight loss is not applicable in this context as the patient has not yet undergone surgery. Therefore, it does not contribute to the chances of positive outcomes post-surgery.
Choice D reason: Recovery close to the hospital can be beneficial as it allows for easier follow-up visits and quicker access to medical care if complications arise. It also reduces the stress associated with travel for postoperative care.
Choice E reason: Recent weight loss prior to surgery is a positive indicator as it shows the patient’s commitment to lifestyle changes and weight management. It can also reduce surgical risk and improve postoperative recovery1.
Choice F reason: While age can be a factor in surgical risk, there is no direct correlation between the client’s age and the chance for positive outcomes after bariatric surgery. Therefore, it is not a contributing factor in this scenario.
Choice G reason: Family support is crucial for a patient’s recovery and long-term success after bariatric surgery. The patient’s plan to go home with her mother, who lives close to the hospital, indicates a strong support system which can help with adherence to dietary and lifestyle changes.
Choice H reason: A high BMI, such as 41.4 kg/m^2, indicates severe obesity, which is the reason for undergoing bariatric surgery. While it is a factor for considering surgery, it does not inherently increase the chance for positive outcomes post-surgery.

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A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care?

Correct Answer is C

Explanation

Patient Data Exhibits The nurse reviews the client data. What increases the client's chance for positive outcomes after the completion of the bariatric surgery? Select all that apply.

Correct Answer is ["A","B","D","E","G"]

Explanation

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