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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.
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A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of bacterial cystitis?
- A. A 36-year-old female who has never been pregnant
- B. A 42-year-old male who is prescribed cephalophamide
- C. A 34-year-old female who is not using estrogen replacement
- D. A 77-year-old male with mild congestive heart failure
Correct Answer: C
Rationale: Females at any age are more susceptible to cystitis than men because of the shorter urethra in women. Postmenopausal women who are not on hormone replacement therapy are at increased risk for bacterial cystitis because of changes in the cells of the urethra and vagina. The middle-aged woman who has never been pregnant would not have a risk potential as high as the older woman who is not using hormone replacement therapy.
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 assesses a client who presents with renal calculi. Which question should the nurse ask?
- A. Do any of your family members have this problem?
- B. Do you drink any cranberry juice?
- C. Do you urinate after sexual intercourse?
- D. Do you experience burning with urination?
Correct Answer: A
Rationale: There is a strong association between family history and stone formation and recurrence. Nephrolithiasis is associated with many genetic variations; therefore, the nurse should ask whether other family members have also had renal stones.
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.
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.