After her bath, a 62-year-old patient asks the nurse for a perineal pad saying that she uses them because sometimes she leaks urine when she laughs or coughs. Which intervention is most appropriate to include in the care plan for the patient?

Teach the patient how to perform Kegel exercises.

Assist the patient to the bathroom q3hr.

Demonstrate how to perform Crede’s maneuver.

Place commode at the patient’s bedside.

Answer and Explanation

The Correct Answer is A

Kegel exercises are designed to strengthen the pelvic ﬂoor muscles, which can help improve urinary incontinence. By teaching the patient how to perform Kegel exercises, the nurse can provide a non-invasive, eﬀective intervention that the patient can perform on her own to help manage her urinary incontinence.

Assisting the patient to the bathroom q3hr (b) may help reduce the frequency of incontinence episodes but it does not address the underlying issue of weakened pelvic ﬂoor muscles.

Demonstrating how to perform Crede’s maneuver (c) involves applying manual pressure to the bladder to assist with urination and is not appropriate for managing urinary incontinence related to laughing or coughing.

Placing a commode at the patient’s bedside (d) may be appropriate for patients who have difficulty with mobility or accessing the bathroom, but it does not address the underlying issue of weakened pelvic ﬂoor muscles causing urinary incontinence.

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Correct Answer is A

Explanation

Excess ﬂuid volume related to intake greater than output would be the most appropriate nursing diagnosis for a patient with symptoms of DI (diabetes insipidus). This condition results in excessive urine output and, as a consequence, can lead to dehydration and electrolyte imbalances. Therefore, monitoring and managing ﬂuid volume is a priority for patients with DI.

Risk for impaired skin integrity related to generalized edema is more commonly associated with conditions that cause ﬂuid retention such as heart failure, liver failure, or kidney disease, rather than DI.

Activity intolerance related to muscle cramps and weakness is a possible nursing diagnosis for patients with conditions that aﬀect muscle function, such as muscular dystrophy or multiple sclerosis, but not specifically for DI.

Insomnia related to waking at night to void is more commonly associated with urinary frequency or nocturia due to conditions such as urinary tract infections or benign prostatic hyperplasia, but not specifically for DI.

A. Fluid restriction B. Administration of hypotonic IV ﬂuids C. Placement of an indwelling urinary catheter D. Administration Of action-exchange resin

Correct Answer is A

Explanation

The plan of care for a patient with hypothermia and ﬂuid volume excess would typically include measures to increase the patient's body temperature and decrease their ﬂuid volume. Therefore, option a (ﬂuid restriction) would be appropriate for this patient.

Options b (administration of hypotonic IV ﬂuids) and d (administration of ion-exchange resin) would not be appropriate because they would increase the patient's ﬂuid volume rather than decrease it.

Option c (placement of an indwelling urinary catheter) may be appropriate to closely monitor the patient's urine output, which is an important indicator of their ﬂuid status. However, this alone would not be sufficient to manage the patient's hypothermia and ﬂuid volume excess.

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After her bath, a 62-year-old patient asks the nurse for a perineal pad saying that she uses them because sometimes she leaks urine when she laughs or coughs. Which intervention is most appropriate to include in the care plan for the patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is creating the care plan for a patient with symptoms of DI who was admited to the hospital for evaluation and treatment of the condition. An appropriate nursing diagnosis for the patient is:

Correct Answer is A

Explanation

The nurse is caring for a patient with hypothermia and ﬂuid volume excess. Which of the following would be included in the plan of care?

Correct Answer is A

Explanation

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