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A patient, age 78, has been admitted to the hospital with dehydration and electrolyte imbalance. The patient is confused and incontinent of urine on admission. Which nursing intervention does the nurse expect to see in the plan of care?
- A. Restrict fluids after the evening meal.
- B. Insert an indwelling catheter.
- C. Assist the patient to the bathroom every 6 hours.
- D. Apply absorbent incontinence pads.
Correct Answer: D
Rationale: Use of protective undergarments may help to keep the patient and the patient's clothing dry. Patients who are confused are high risk for falls. Restricting fluids will only decrease incontinence during the night and will exacerbate the dehydration and electrolyte imbalance.
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As the nurse and the dietitian review a female patient's diet plan with her, she shouts that with her diabetes and now the kidney failure, there is just nothing she can eat. She says she might as well eat what she wants, because there is nothing she can do to help herself. Based on the patient's response, which patient problem does the nurse identify?
- A. The patient will not likely follow a prescribed diet due to anger.
- B. The patient does not understand the diet, and will likely have poor nutrition.
- C. The patient is in the grieving process, due to the probability she will die soon.
- D. The patient is feeling unable to cope, and feels helpless over having diabetes and kidney failure.
Correct Answer: D
Rationale: Ineffective coping due to the feeling of powerlessness against the multiorgan failure may result in aggressive or infantile behavior.
The nurse is aware that as a person ages there is a loss of which mechanism of the kidney due to a decrease in blood supply to the kidneys and loss of nephrons?
- A. filtering
- B. reabsorption
- C. sterile water
- D. concentrating
Correct Answer: A
Rationale: The filtering mechanism is most affected with aging.
In which way will the nurse instruct the patient to do before obtaining the urine specimen for a urine culture?
- A. Collect the urine for a 24-hour period.
- B. Obtain a clean-catch specimen.
- C. Bring in an early morning specimen.
- D. Limit fluid intake to concentrate the urine.
Correct Answer: B
Rationale: Urine cultures are dependent on a clean-catch or catheterized specimen.
An intravenous pyelogram confirms the presence of a large renal calculus in the proximal left ureter of a newly admitted patient. The patient is not a candidate for conservative measures, so surgical correction is recommended. In addition to observing the patient for hemorrhage, which aspect of care will be the nurse's postsurgical interventions included for this patient?
- A. Encouraging fluid intake
- B. Addressing anxiety related to unclear outcome of condition
- C. Monitoring the patient for signs of prostatic hypertrophy
- D. Recommending appropriate oral analgesics to the health care provider
Correct Answer: A
Rationale: After surgery, encourage fluid intake to prevent infection and to prevent further stones from developing.
It is 2 days after a 42-year-old male patient's urinary diversion surgery. He continues to be critical of the hospital and the nursing care, even though the staff has spent time explaining the care to him. Which explanation is most likely for his behavior?
- A. He is angry about hospital policy.
- B. He is feeling neglected by the nursing staff.
- C. He is in denial of the effects of the surgery.
- D. He is reacting to the loss of self-esteem and altered body image.
Correct Answer: D
Rationale: Persons with altered body image may react to the loss of self-esteem by behaving in a critical or derogatory manner.