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A patient has undergone the creation of an Indiana pouch for the treatment of bladder cancer. The nurse identified the nursing diagnosis of disturbed body image. How can the nurse best address the effects of this urinary diversion on the patients body image?
- A. Emphasize that the diversion is an integral part of successful cancer treatment.
- B. Encourage the patient to speak openly and frankly about the diversion.
- C. Allow the patient to initiate the process of providing care for the diversion.
- D. Provide the patient with detailed written materials about the diversion at the time of discharge.
Correct Answer: B
Rationale: Allowing the patient to express concerns and anxious feelings can help with body image, especially in adjusting to the changes in toileting habits. The nurse may have to initiate dialogue about the management of the diversion, especially if the patient is hesitant. Provision of educational materials is rarely sufficient to address a sudden change and profound change in body image. Emphasizing the role of the diversion in cancer treatment does not directly address the patients body image.
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The clinic nurse is preparing a plan of care for a patient with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach?
- A. Provide medication teaching related to pseudoephedrine sulfate.
- B. Teach the patient to perform pelvic floor muscle exercises.
- C. Prepare the patient for an anterior vaginal repair procedure.
- D. Provide information on periurethral bulking.
Correct Answer: B
Rationale: Pelvic floor muscle exercises (sometimes called Kegel exercises) represent the cornerstone of behavioral intervention for addressing symptoms of stress, urge, and mixed incontinence. None of the other listed interventions has a behavioral approach.
The nurse is assessing a patient admitted with renal stones. During the admission assessment, what parameters would be priorities for the nurse to address? Select all that apply.
- A. Dietary history
- B. Family history of renal stones
- C. Medication history
- D. Surgical history
- E. Vaccination history
Correct Answer: A,B,C
Rationale: Dietary and medication histories and family history of renal stones are obtained to identify factors predisposing the patient to stone formation. When caring for a patient with renal stones it would not normally be a priority to assess the vaccination history or surgical history, since these factors are not usually related to the etiology of kidney stones.
The nurse is collaborating with the wound-ostomy-continence (WOC) nurse to teach a patient how to manage her new ileal conduit in the home setting. To prevent leakage or skin breakdown, the nurse should encourage which of the following practices?
- A. Empty the collection bag when it is between one-half and two-thirds full.
- B. Limit fluid intake to prevent production of large volumes of dilute urine.
- C. Reinforce the appliance with tape if small leaks are detected.
- D. Avoid using moisturizing soaps and body washes when cleaning the peristomal area.
Correct Answer: D
Rationale: The patient is instructed to avoid moisturizing soaps and body washes when cleaning the area because they interfere with the adhesion of the pouch. To maintain skin integrity, a skin barrier or leaking pouch is never patched with tape to prevent accumulation of urine under the skin barrier or faceplate. Fluids should be encouraged, not limited, and the collection bag should not be allowed to become more than one-third full.
A nurse is working with a female patient who has developed stress urinary incontinence. Pelvic floor muscle exercises have been prescribed by the primary care provider. How can the nurse best promote successful treatment?
- A. Clearly explain the potential benefits of pelvic floor muscle exercises.
- B. Ensure the patient knows that surgery will be required if the exercises are unsuccessful.
- C. Arrange for biofeedback when the patient is learning to perform the exercises.
- D. Contact the patient weekly to ensure that she is performing the exercises consistently.
Correct Answer: C
Rationale: Research shows that written or verbal instruction alone is usually inadequate to teach an individual how to identify and strengthen the pelvic floor for sufficient bladder and bowel control. Biofeedback-assisted pelvic muscle exercise (PME) uses either electromyography or manometry to help the individual identify the pelvic muscles as he or she attempts to learn which muscle group is involved when performing PME. This objective assessment is likely superior to weekly contact with the patient. Surgery is not necessarily indicated if behavioral techniques are unsuccessful.
A gerontologic nurse is assessing a patient who has numerous comorbid health problems. What assessment findings should prompt the nurse to suspect a UTI? Select all that apply.
- A. Food cravings
- B. Upper abdominal pain
- C. Insatiable thirst
- D. Uncharacteristic fatigue
- E. New onset of confusion
Correct Answer: D,E
Rationale: The most common subjective presenting symptom of UTI in older adults is generalized fatigue. The most common objective finding is a change in cognitive functioning. Food cravings, increased thirst, and upper abdominal pain necessitate further assessment and intervention, but none is directly suggestive of a UTI.