Nokea
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.
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A patient who has recently undergone ESWL for the treatment of renal calculi has phoned the urology unit where he was treated, telling the nurse that he has a temperature of101.1 \mathrm{~F}(38.4 \mathrm{C})$. How should the nurse best respond to the patient?
- A. Remind the patient that renal calculi have a noninfectious etiology and that a fever is unrelated to their recurrence.
- B. Remind the patient that occasional febrile episodes are expected following ESWL.
- C. Tell the patient to report to the ED for further assessment.
- D. Tell the patient to monitor his temperature for the next 24 hours and then contact his urologists office.
Correct Answer: C
Rationale: Following ESWL, the development of a fever is abnormal and is suggestive of a UTI; prompt medical assessment and treatment are warranted. It would be inappropriate to delay further treatment.
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.
A patient has a flaccid bladder secondary to a spinal cord injury. The nurse recognizes this patients high risk for urinary retention and should implement what intervention in the patients plan of care?
- A. Relaxation techniques
- B. Sodium restriction
- C. Lower abdominal massage
- D. Double voiding
Correct Answer: D
Rationale: To enhance emptying of a flaccid bladder, the patient may be taught to double void. After each voiding, the patient is instructed to remain on the toilet, relax for 1 to 2 minutes, and then attempt to void again in an effort to further empty the bladder. Relaxation does not affect the neurologic etiology of a flaccid bladder. Sodium restriction and massage are similarly ineffective.
A patient has been admitted to the postsurgical unit following the creation of an ileal conduit. What should the nurse measure to determine the size of the appliance needed?
- A. The circumference of the stoma
- B. The narrowest part of the stoma
- C. The widest part of the stoma
- D. Half the width of the stoma
Correct Answer: C
Rationale: The correct appliance size is determined by measuring the widest part of the stoma with a ruler. The permanent appliance should be no more than1.6 \mathrm{~mm}$ (1 / 8$ inch) larger than the diameter of the stoma and the same shape as the stoma to prevent contact of the skin with drainage.
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.