The nurse is identifying outcomes for a client with the nursing diagnosis of Stress Urinary Incontinence. Which outcome would be related to sphincter incompetence?

The client will perform four to five isometric squeezes for 5 to 10 seconds.

The client will empty her bladder completely each time she voids.

The client will improve her incontinence within one month.

The client will stop the ﬂow of urine when voiding.

Answer and Explanation

The Correct Answer is A

Stress urinary incontinence is the involuntary loss of urine during physical activity such as coughing, sneezing, or exercising. It is often caused by weakness of the pelvic ﬂoor muscles and/or the urethral sphincter. An appropriate outcome for a client with this condition would be to improve the strength of these muscles. Performing isometric squeezes, also known as Kegel exercises, can help strengthen the pelvic ﬂoor muscles and improve sphincter competence. This can help reduce or prevent episodes of incontinence.

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Correct Answer is D

Explanation

A stage II pressure ulcer is a wound that involves partial-thickness loss of skin. The most appropriate NANDA nursing diagnosis problem statement for a client with this condition would be Impaired Skin Integrity. This diagnosis reﬂects the fact that the client's skin has been damaged and is no longer intact. Risk for Injury, Altered Tissue Perfusion, and Impaired Tissue Integrity are also NANDA nursing diagnoses, but they are not as specific or relevant to the client's condition as Impaired Skin Integrity.

A. "I will restrict my diet to fats and carbohydrates." B. "I will drink 8 to 10 glasses of water every day." C. "I will take the zinc supplement the doctor recommended." D. "I will drink a lot of orange juice and drink milk, too." E. Noncompliance (DASH diet) related to denial of having the disease.

Correct Answer is A

Explanation

This statement by the client would indicate a need for further information about essential nutrition for healing. A balanced diet that includes a variety of nutrients is important for postoperative healing. Restricting the diet to only fats and carbohydrates may not provide all the necessary nutrients for optimal healing. The nurse should provide further education to the client about the importance of a balanced diet that includes protein, vitamins, and minerals in addition to fats and carbohydrates.

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The nurse is identifying outcomes for a client with the nursing diagnosis of Stress Urinary Incontinence. Which outcome would be related to sphincter incompetence?

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Naxlex Comprehensive Predictor Exams

The client has a documented stage II pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate to use with this client?

Correct Answer is D

Explanation

A nurse is educating a postoperative client on essential nutrition for healing. Which statement by the client would indicate a need for information?

Correct Answer is A

Explanation

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

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