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A nurse cares for a client admitted from a nursing home after several recent falls. What prescription should the nurse complete first?
- A. Obtain urine sample for culture and sensitivity.
- B. Administer intravenous antibiotics.
- C. Encourage protein intake and additional fluids.
- D. Consult physical therapy for gait training.
Correct Answer: A
Rationale: Although all interventions are or might be important, obtaining a urine sample for urinalysis takes priority. Often urinary tract infection (UTI) symptoms in older adults are atypical, and a UTI may present with new onset of confusion or falling. The urine sample should be obtained before starting antibiotics.
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After teaching a client who has stress incontinence, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
- A. I must avoid drinking alcoholic beverages.
- B. I must avoid drinking alcoholic beverages.
- C. I must avoid drinking caffeinated beverages.
- D. I must try to drink caffeinated body weight.
Correct Answer: A
Rationale: Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence. Many people try to manage incontinence by limiting fluids. Alcohol and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.
After delegating care to an unlicensed assistive personnel (UAP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the UAP's understanding. Which action indicates the UAP needs additional teaching?
- A. Toileting the client after breakfast
- B. Changing the client's incontinence brief when wet
- C. Encouraging the client to drink fluids
- D. Recording the client's incontinence episodes
Correct Answer: B
Rationale: Habit training is undermined by the use of absorbent incontinence briefs or pads. The nurse should re-educate the UAP on the technique of habit training. The UAP should continue to toilet the client after meals, encourage the client to drink fluids, and record incontinence episodes.
A nurse assesses a client for risk factors for bladder cancer. Which question should the nurse ask?
- A. Do you smoke cigarettes?
- B. Do you use recreational drugs?
- C. Do you consume alcohol regularly?
- D. Do you have a family history of bladder cancer?
Correct Answer: A
Rationale: Smoking is known to be a factor that greatly increases the risk of bladder cancer. Alcohol use, recreational drug use, and family history (except medications that contain phenacetin) are not known to significantly increase the risk of developing bladder cancer.
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.
A nurse plans care for clients with urinary incontinence. Which client is correctly paired with the appropriate intervention?
- A. A 24-year-old female post vaginal delivery: Habit training
- B. A 58-year-old postmenopausal client who is not taking estrogen therapy: Electrical stimulation
- C. A 64-year-old female with Alzheimer's-type senile dementia: Bladder training
- D. A 7-year-old female who has difficulty ambulating: Exercise therapy
Correct Answer: B
Rationale: Exercise therapy and electrical stimulation are used for clients with stress incontinence related to childbirth or low levels of estrogen after menopause. Exercise therapy increases pelvic wall strength; it does not improve ambulation. Habit training is the type of bladder training that will be most effective for cognitively impaired clients.