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A nurse assesses a client who is recovering from extracorporeal shock wave lithotripsy for renal calculi. The nurse notes an ecchymotic area on the client's right lower back. Which action should the nurse take?
- A. Apply an ice pack to the site.
- B. Apply an ice pack to the site.
- C. Place the client in the prone position.
- D. Obtain serum coagulation test results.
Correct Answer: A
Rationale: The shock waves from lithotripsy can cause bleeding into the tissues through which the waves pass. Application of ice can reduce the extent and discomfort of the bruising. Although coagulation test results and fresh-frozen plasma are used to assess and treat bleeding disorders, ecchymosis after this procedure is not unusual. Obtaining serum coagulation is a higher level of intervention. Changing the client's position will not decrease bleeding.
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An emergency department nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question should the nurse ask first?
- A. Are you drinking plenty of water?
- B. What medications are you taking?
- C. Have you tried laxatives or enemas?
- D. Has this type of thing ever happened before?
Correct Answer: B
Rationale: Some types of incontinence are treated with anticholinergic medications such as propantheline (Pro-Banthine). Anticholinergic side effects include dry mouth, constipation, and urinary retention. The nurse needs to assess the client's medication list to determine whether the client is taking an anticholinergic medication.
A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which questions should the nurse ask?
- A. How much water do you drink every day?
- B. Do you take estrogen replacement therapy?
- C. Does anyone in your family have a history of cystitis?
- D. Do you take any immune-suppressing drugs?
- E. Do you drink grapefruit juice or orange juice daily?
Correct Answer: A,B,D
Rationale: Fluid intake, estrogen levels, and immune suppression all can increase the chance of recurrent cystitis. Family history is usually insignificant, and cranberry juice, not grapefruit or orange juice, has been found to increase the acidity and reduce the risk for bacterial cystitis.
A nurse teaches a female client who has stress incontinence. Which statements should the nurse include in this client's teaching?
- A. When you start and stop your urine stream, you are using your pelvic muscles.
- B. Tighten your pelvic muscles for a slow count of 10 and then relax for a slow count of 10.
- C. Pelvic muscle exercises should only be performed sitting straight with your feet on the floor.
- D. After you have been using these exercises for a couple days, your control of urine will improve.
- E. Like any other muscle in your body, you can make your pelvic muscles stronger by contracting them.
Correct Answer: A,B,E
Rationale: The client should be taught that the muscles used to start and stop urination are pelvic muscles, and that pelvic muscles can be strengthened by contracting and relaxing them. The client should tighten pelvic muscles for a slow count of 10 and then relax the muscles for a slow count of 10 in various positions.
A nurse teaches a client with functional urinary incontinence. Which statement should the nurse include in this client's teaching?
- A. You must clean around your catheter daily with soap and water.
- B. You must clean around your catheter daily with soap and water.
- C. You must clean around your catheter daily with soap and water.
- D. Operations to repair your bladder are available, and you can consider these.
- E. Buy slacks with elastic waistbands that are easy to pull down.
Correct Answer: E
Rationale: Functional urinary incontinence occurs as the result of problems not related to the client's bladder, such as trouble accessing a toilet. One goal is that the client be able to manage his or her clothing independently. Elastic waistband slacks that are easy to pull down can help the client get on the toilet in time to void. The other instructions do not relate to functional urinary incontinence.
A nurse teaches a client who is starting urinary bladder training. Which statement should the nurse include in this client's teaching?
- A. Use the toilet when you first feel the urge, rather than at specific intervals.
- B. Try to consciously hold your urine until the scheduled toileting time.
- C. The client needs to determine whether the client is taking a 24 hours.
- D. The toileting interval can be increased once you have been continent for a week.
Correct Answer: B
Rationale: The client should try to hold the urine consciously until the next scheduled toileting time. Toileting should occur at specific intervals during the training. The toileting interval should be no less than every hour.