Nokea
The nurse is providing care for an older adult man whose diagnosis of dementia has recently led to urinary incontinence. When planning this patients care, what intervention should the nurse avoid?
- A. Scheduled toileting
- B. Indwelling catheter
- C. External condom catheter
- D. Incontinence pads
Correct Answer: B
Rationale: Indwelling catheters are avoided if at all possible because of the high incidence of urinary tract infections with their use. Intermittent self-catheterization is an appropriate alternative for managing reflex incontinence, urinary retention, and overflow incontinence related to an overdistended bladder. External catheters (condom catheters) and leg bags to collect spontaneous voiding are useful for male patients with reflex or total incontinence. Incontinence pads should be used as a last resort because they only manage, rather than solve, the incontinence.
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A patient has been transferred to a rehabilitative setting from an acute care unit. What is the most important reason for the nurse to begin a program for activities of daily living (ADLs) as soon as the patient is admitted to a rehabilitation facility?
- A. The ability to perform ADLs may be the key to dependence.
- B. The ability to perform ADLs is essential to living in a group home.
- C. The ability to perform ADLs may be the key to reentry into the community.
- D. The ability to perform ADLs is necessary to function in an assisted-living situation.
Correct Answer: C
Rationale: An ADL program is started as soon as the rehabilitation process begins because the ability to perform ADLs is frequently the key to independence, return to the home, and reentry into the community. ADLs are frequently the key to independence, not dependence. The ability to perform ADLs is not always a criterion for admission to a group home or assisted-living facility.
A female patient, 47 years old, visits the clinic because she has been experiencing stress incontinence when she sneezes or exercises vigorously. What is the best instruction the nurse can give the patient?
- A. Keep a record of when the incontinence occurs.
- B. Perform clean intermittent self-catheterization.
- C. Perform Kegel exercises four to six times per day.
- D. Wear a protective undergarment to address this age-related change.
Correct Answer: C
Rationale: For cognitively intact women who experience stress incontinence, the nurse should instruct the patient to perform Kegel exercises four to six times per day to strengthen the pubococcygeus muscle. Keeping a record of when the incontinence occurs or accepting incontinence as part of aging are incorrect answers because they are of no value in treating stress incontinence. Women with stress incontinence do not need clean intermittent catheterization. Protective undergarments hide the effects of urinary incontinence but they do not resolve the problem.
An elderly female patient who is bedridden is admitted to the unit because of a pressure ulcer that can no longer be treated in a community setting. During your assessment of the patient, you find that the ulcer extends into the muscle and bone. At what stage would document this ulcer?
- A. I
- B. II
- C. III
- D. IV
Correct Answer: D
Rationale: Stage III and IV pressure ulcers are characterized by extensive tissue damage. In addition to the interventions listed for stage I, these advanced draining, necrotic pressure ulcers must be cleaned (dbrided) to create an area that will heal. Stage IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer that extends into the subcutaneous tissue. With this type of ulcer, necrosis of tissue and infection may develop. Stage I is an area of erythema that does not blanch with pressure. Stage II involves a break in the skin that may drain.
You are caring for a 35-year-old man whose severe workplace injuries necessitate bilateral below-theknee amputations. How can you anticipate that the patient will respond to this news?
- A. The patient will go through the stages of grief over the next week to 10 days.
- B. The patient will progress sequentially through five stages of the grief process.
- C. The patient will require psychotherapy to process his grief.
- D. The patient will experience grief in an individualized manner.
Correct Answer: D
Rationale: Loss of limb is a profoundly emotional experience, which the patient will experience in a subjective manner, and largely unpredictable, manner. Psychotherapy may or may not be necessary. It is not possible to accurately predict the sequence or timing of the patients grief. The patient may or may not benefit from psychotherapy.
You are admitting a patient into your rehabilitation unit after an industrial accident. The patients nursing diagnoses include disturbed sensory perception and you assess that he has decreased strength and dexterity. You know that this patient may need what to accomplish self-care?
- A. Advice from his family
- B. Appropriate assistive devices
- C. A personal health care aide
- D. An assisted-living environment
Correct Answer: B
Rationale: Patients with impaired mobility, sensation, strength, or dexterity may need to use assistive devices to accomplish self-care. An assisted-living environment is less common than the use of assistive devices. Family involvement is imperative, but this may or may not take the form of advice. A healthcare aide is not needed by most patients.