What would be the best nursing action to facilitate bladder continence for the client who is cognitively impaired?

Offer toileting reminders every 2 hours

Provide clothing that is easy to manipulate

Explain the need to call for the nurse to help with toileting

Encourage avoidance of fluids between meals

Answer and Explanation

The Correct Answer is A

A. Offer toileting reminders every 2 hours: This is the best nursing action because it helps prevent urinary incontinence by prompting the client to use the bathroom regularly. Clients with cognitive impairment may have difficulty recognizing the need to void or remembering when to do so. Providing frequent reminders helps maintain bladder continence and reduces the risk of accidents.

B. Provide clothing that is easy to manipulate: While providing clothing that is easy to manipulate can be helpful for clients with cognitive impairment to independently manage toileting, it does not directly address the issue of facilitating bladder continence. Easy-to-manipulate clothing may assist with toileting independence but does not address the need for regular voiding to prevent urinary incontinence.

C. Explain the need to call for the nurse to help with toileting: While educating the client about when to seek assistance for toileting needs is important, it may not be sufficient for facilitating bladder continence in a client with cognitive impairment. Clients may still have difficulty recognizing the need to void or remembering to call for assistance, making frequent reminders more effective in promoting continence.

D. Encourage avoidance of fluids between meals: Encouraging avoidance of fluids between meals is not an appropriate strategy for promoting bladder continence. Restricting fluids can lead to dehydration and other health complications. Maintaining adequate hydration is essential for overall health, and clients should be encouraged to drink fluids regularly throughout the day. Additionally, restricting fluids does not address the underlying issue of cognitive impairment affecting toileting behaviors.

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Correct Answer is A

Explanation

A. Daily weights, vital signs, and fluid intake and output: These are essential nursing assessments and interventions that can be implemented without a physician's order to monitor the client's fluid volume deficit and hypovolemia. Daily weights help assess changes in fluid status, vital signs provide information on the client's hemodynamic stability, and monitoring fluid intake and output helps track fluid balance.

B. Monitoring temperature, fluid intake and output, and administering IV fluids: While monitoring temperature and fluid intake and output are important aspects of nursing care, administering IV fluids typically requires a physician's order, especially in the context of hypovolemia. The nurse should collaborate with the healthcare team to determine the need for IV fluid therapy.

C. Auscultation of lung sounds, monitoring urine color, and placing an indwelling urinary catheter in the client: Auscultation of lung sounds and monitoring urine color are relevant assessments for fluid volume status, but placing an indwelling urinary catheter typically requires a physician's order unless there is a specific nursing protocol in place allowing nurses to insert catheters under certain circumstances.

D. Daily weights, diuretics, and waist measurement: While daily weights are appropriate for assessing fluid status, administering diuretics should be based on a physician's order and assessment findings. Waist measurement is not typically used to assess fluid volume deficit and hypovolemia.

A. that both partners are in good health. B. being of the same sociocultural background. C. open communication. D. awareness of the partner's needs.

Correct Answer is C

Explanation

A. That both partners are in good health: While good health can contribute to a satisfying sexual relationship, it is not the sole determinant. Health status alone does not guarantee a mutually-satisfying sexual relationship.

B. Being of the same sociocultural background: While sharing a sociocultural background may facilitate understanding and communication in some cases, it is not a universal requirement for a healthy sexual relationship. Partners from diverse backgrounds can have fulfilling relationships with effective communication and mutual respect.

C. Open communication: Open communication is essential for building trust, understanding preferences, expressing needs and desires, and resolving conflicts in a sexual relationship. It allows partners to discuss their feelings, concerns, and expectations openly, leading to greater intimacy and satisfaction.

D. Awareness of the partner's needs: Being aware of the partner's needs is important, but without open communication, it can be challenging to understand those needs fully. Open communication facilitates the expression and acknowledgment of needs, making it easier for partners to address them effectively.

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What would be the best nursing action to facilitate bladder continence for the client who is cognitively impaired?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a fluid volume deficit and hypovolemia. What actions can the nurse take without a physician's order?

Correct Answer is A

Explanation

When working with clients of any age, the nurse keeps in mind that the key to mutually-satisfying, healthy sexual relationships between partners is most often:

Correct Answer is C

Explanation

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