The 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?
Suggest contacting the healthcare provider for a prescription for catheter insertion.
Recommend a complete bath to cleanse the perineal area more fully.
Evaluate the effectiveness of this measure to stimulate client voiding.
Instruct the PN that this technique promotes infection in elderly females.
The Correct Answer is C
A. Suggest contacting the healthcare provider for a prescription for catheter insertion: Catheter insertion may not be necessary if the client is able to void with this technique. It's important to evaluate less invasive measures first.
B. Recommend a complete bath to cleanse the perineal area more fully: While cleanliness is important, the immediate concern is addressing urinary incontinence and promoting voiding.
C. Evaluate the effectiveness of this measure to stimulate client voiding: Warm water can sometimes stimulate voiding reflexes in clients who have difficulty emptying their bladders. Assessing the client's response to this measure is appropriate.
D. Instruct the PN that this technique promotes infection in elderly females: Pouring warm water over the perineal area does not necessarily promote infection, especially if proper hygiene
measures are followed. It's important to assess the effectiveness of the intervention before assuming it is inappropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Depression: While depression may occur in some individuals with Wernicke's syndrome, confusion is the primary assessment finding associated with this condition.
B. Right lower abdominal pain: Abdominal pain is not a characteristic symptom of Wernicke's syndrome. Confusion, ophthalmoplegia, and ataxia are more common.
C. Peripheral neuropathy: While peripheral neuropathy may occur in some neurological conditions, it is not specific to Wernicke's syndrome, which primarily presents with confusion, ophthalmoplegia, and ataxia.
D. Confusion: Confusion is a hallmark symptom of Wernicke's syndrome and should be a primary focus of assessment and care planning for this condition.
Correct Answer is ["D","F","G"]
Explanation
A. Encourage three large meals a day. This may not be appropriate for the client's current dietary plan, especially after bariatric clinic involvement and dietitian consultations.
B. Start with room temperature water. While hydration is important, this advice is too vague and does not consider the client's specific nutritional needs or restrictions.
C. Anticipate weight loss will continue even with normal diet. Weight loss should be monitored and managed carefully, especially after bariatric treatment; it should not be assumed to continue without ongoing effort and adherence to a dietary plan.
D. Walk frequently during recovery. Encourage the client to continue with regular, gentle walks as tolerated to promote circulation and weight management, which is consistent with the client's recent weight loss through walking.
E. Expect immediate return of ovulation. There is no information provided that correlates the client's medical condition with ovulation status.
F. Begin taking supplements per the healthcare provider's orders. If the healthcare provider has recommended supplements, ensure the client understands the importance of taking them as directed to support overall health.
G. Advance diet from clear liquids to full liquid. As the client recovers, it's important to gradually reintroduce different types of food, starting with clear liquids and moving to full liquids as tolerated before progressing to solid foods.
H. Dietician appointments are optional. Given the client's history with weight management and engagement with a bariatric clinic, continued dietitian support is likely crucial for sustained success.
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