Which nursing action is the priority intervention for a client diagnosed with total urinary incontinence?

Toileting routine.

Kegel exercises.

Surgery.

Anticholinergic drug therapy.

Answer and Explanation

The Correct Answer is A

A toileting routine is the priority intervention for a client diagnosed with total urinary incontinence because it helps to prevent skin breakdown, infection, and odor. It also promotes dignity and comfort for the client.

Choice B. Kegel exercises are wrong because they are not effective for total urinary incontinence, which is the complete loss of bladder control. Kegel exercises are more useful for stress or urge urinary incontinence, which are caused by weak pelvic floor muscles.

Choice C. Surgery is wrong because it is not a priority intervention for total urinary incontinence.

Surgery may be considered a last resort option if other conservative measures fail to improve the condition. Surgery may also have risks and complications that need to be weighed against the benefits.

Choice D. Anticholinergic drug therapy is wrong because it is not a priority intervention for total urinary incontinence.

Anticholinergic drugs are used to treat overactive bladder or urge urinary incontinence, which are caused by involuntary bladder contractions. Anticholinergic drugs may have side effects such as dry mouth, constipation, blurred vision, and confusion.

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Correct Answer is C

Explanation

The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. This action is not appropriate in the prevention of liability because it violates the client’s right to receive care and may be considered as discrimination or abandonment. The nurse has a duty to provide care to all clients regardless of their personal feelings or preferences.

Choice A is wrong because establishing rapport with the client in an inpatient psychiatric setting is an appropriate action to prevent liability. It helps to build trust and communication between the nurse and the client and reduces the risk of misunderstanding or conflict.

Choice B is wrong because documenting accurately and honestly in the electronic health record is an appropriate action to prevent liability. It provides evidence of the care provided, the client’s condition and response, and any incidents or complications that occurred.

Choice D is wrong because referring to the policy of the inpatient psychiatric setting when uncertain of a standard of care is an appropriate action to prevent liability. It helps the nurse to follow the best practices and guidelines for providing safe and effective care to the client.

A. “Would you like me to get you some tissues?”. B. “I see that you’re upset. I’ll come back later.”. C. “I see that you’re crying. Tell me about it.”. D. “How can I help you?”.

Correct Answer is C

Explanation

Tell me about it.” This response by the nurse would best facilitate communication because it acknowledges the client’s emotional state and invites the client to express their feelings.

It also shows empathy and respect for the client.

Choice A is wrong because it does not address the client’s emotional needs or encourage communication.

It also implies that the nurse is uncomfortable with the client’s crying and wants to avoid it. Choice B is wrong because it does not show empathy or support for the client.

It also indicates that the nurse is too busy or unwilling to listen to the client.

Choice D is wrong because it is too vague and does not acknowledge the client’s emotional state.

It also puts the burden on the client to come up with a solution for their problem.

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Which nursing action is the priority intervention for a client diagnosed with total urinary incontinence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse takes actions to avoid liability when caring for a client with a psychiatric disorder. Which action is not appropriate in the prevention of liability?

Correct Answer is C

Explanation

A nurse finds a client who is awaiting the results of diagnostic tests sitting in bed crying. Which response by the nurse would best facilitate communication?

Correct Answer is C

Explanation

The nurse is assessing a client experiencing acute pain. What assessments should validate the client with acute pain? Select all that apply.

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