A nurse in a long-term facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client’s incontinence, which of the following interventions should the nurse initiate to manage this behavior?

Take the client to the bathroom every 2 hr.

Request a prescription for an indwelling urinary catheter

Remind the client to tell the nurse when he has to urinate.

Use adult diapers to prevent frequent clothing changes.

Answer and Explanation

The Correct Answer is A

Choice A reason: Scheduled toileting every 2 hours establishes a routine, compensating for dementia-related cognitive deficits in recognizing bladder cues. This promotes continence, reduces accidents, and maintains dignity, making it the most effective behavioral intervention.

Choice B reason: Indwelling catheters increase risks of urinary tract infections, skin breakdown, and discomfort, especially in dementia patients unable to communicate issues. They are a last resort, not appropriate for managing incontinence without medical necessity.

Choice C reason: Reminding a dementia patient to report urination needs is ineffective, as cognitive impairment limits their ability to recognize or communicate bladder signals. This approach does not address the underlying issue of incontinence.

Choice D reason: Adult diapers manage accidents but do not promote continence or address the behavior. They may reduce dignity and increase skin breakdown risk, making scheduled toileting a more proactive and dignified intervention.

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Correct Answer is D

Explanation

Choice A reason: Offering narcotics immediately without assessing pain details or considering nonpharmacological options is not therapeutic. Pain management requires a tailored approach, evaluating pain characteristics and patient preferences, as narcotics carry risks like respiratory depression, especially post-surgery, necessitating cautious use.

Choice B reason: Dismissing pain based on stable vitals is not therapeutic. Pain is subjective, and normal vitals (e.g., 110/60 mmHg, 60 bpm) don’t negate severe pain. This response invalidates the patient’s experience, potentially eroding trust and delaying effective pain management.

Choice C reason: Stating the patient doesn’t look in pain is dismissive and non-therapeutic. Pain is subjective, and external appearance may not reflect internal experience, especially in stoic patients. This response risks undermining patient trust and delaying appropriate pain relief interventions.

Choice D reason: Asking what the patient wants to try is therapeutic, promoting patient-centered care. It validates the patient’s pain, encourages shared decision-making, and considers both pharmacological and nonpharmacological options, optimizing pain relief while respecting patient autonomy and preferences post-surgery.

A. Choose a time based on the patient’s pattern to initiate defecation-control measures. B. Lean backward on the hips while sitting on the toilet C. Maintain normal exercise within the patient’s physical ability. D. Record times when the patient is incontinent E. Help the patient to the toilet at the designated time. F. Apply pressure with hands over the abdomen and strain while pushing

Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason: Choosing a time based on the patient’s defecation pattern leverages the gastrocolic reflex, promoting regular bowel movements. Scheduled toileting aligns with natural rhythms, enhancing bowel training success and reducing incontinence episodes.

Choice B reason: Leaning backward on the toilet is not recommended, as it misaligns the anorectal angle, hindering defecation. A forward-leaning or squatting position facilitates easier stool passage, making this action incorrect for bowel training.

Choice C reason: Normal exercise stimulates peristalsis through abdominal muscle movement and increased blood flow to the gut. Within the patient’s ability, it supports regular bowel function, making it an essential component of a bowel training program.

Choice D reason: Recording incontinence times identifies patterns and triggers, allowing tailored interventions. This data informs adjustments to the toileting schedule or dietary changes, improving the effectiveness of the bowel training program.

Choice E reason: Helping the patient to the toilet at designated times ensures adherence to the scheduled toileting plan, especially for those with mobility or cognitive issues. It promotes continence and reinforces the bowel training routine.

Choice F reason: Applying abdominal pressure and straining (Valsalva maneuver) risks pelvic floor strain, hemorrhoids, or cardiovascular stress. Gentle defecation with proper positioning is safer and more effective, making this action inappropriate for bowel training.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who recently had abdominal surgery and is experiencing severe pain. The patient’s blood pressure is 110/60 mmHg, and heart rate is 60 beats/min. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic?

Correct Answer is D

Explanation

A nurse is preparing a bowel training program for a patient. Which actions will the nurse take? (Select all that apply)

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client?

A patient expresses concerns over having black stool. The fecal occult blood test is negative. Which response by the nurse is most appropriate?

A patient is receiving opioids for pain. Which bowel assessment is a priority?

The nurse is caring for different 4 clients. Which of the following client assessments would cause the most concern for the nurse?

A nurse is obtaining a 24-hour urine specimen collection from the patient. Which action should the nurse take?

The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse’s action?