A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?
- A. Teach the client techniques for performing intermittent catheterization
- B. Increase the client's fluid intake to promote frequent urination.
- C. Suggest the use of incontinence pads for comfort
- D. Administer anticholinergic medications to enhance bladder function.
Correct Answer: A
Rationale: Intermittent catheterization helps manage urinary retention and prevents complications like urinary tract infections.
You may also like to solve these questions
Which statement by a parent of an infant with congestive heart failure (CHF) who is being sent home on digoxin indicates the need for further education?
- A. I will give the medication at regular 12-hour intervals.
- B. If he vomits, I will not give a make-up dose.
- C. If I miss a dose, I will not give an extra dose.
- D. I will mix the digoxin in some formula to make it taste better.
Correct Answer: D
Rationale: Mixing digoxin with formula can lead to incomplete ingestion and inadequate dosing. Digoxin must be given in its entirety at the prescribed times.
The parents of a child, age 6, who will begin school in the fall ask the nurse for anticipatory guidance. The nurse should explain that a child of this age:
- A. Still depends on the parents
- B. Rebels against scheduled activities
- C. Is highly sensitive to criticism
- D. Loves to tattle
Correct Answer: C
Rationale: A 6-year-old child is typically highly sensitive to criticism as they are developing self-esteem and are influenced by feedback from adults and peers.
The following are true statements:
- A. Tissue plasminogen activator is derived from endothelium
- B. Heparin acts through antithrombin III
- C. Protein C deficiency is autosomal recessive transmitted
- D. Protein C is vitamin K dependent
Correct Answer: B
Rationale: Heparin acts through antithrombin III: Heparin enhances the activity of antithrombin III, which inhibits thrombin and other clotting factors, helping prevent clot formation.
A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanasthesia unit. Before selecting which medication to administer, which action should the nurse implement?
- A. Document the client's report of pain in the electronic medical record
- B. Determine which prescription will have the quickest onset of action
- C. Compare the client's pain scale rating with the prescribed dosing
- D. Ask the client to choose which mediation is needed for pain
Correct Answer: C
Rationale: Comparing the pain scale rating with the prescribed dosing ensures that the appropriate medication is administered based on the severity of the pain.
After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement?
- A. Call respiratory therapy to give a breathing treatment
- B. Send another nurse for an emergency tracheotomy set
- C. Prepare a dose of epinephrine (Adrenalin)
- D. Review the client's complete list of allergies
Correct Answer: C
Rationale: Shortness of breath and itching are signs of an allergic reaction to the contrast medium, and epinephrine is the first-line treatment for anaphylaxis.