A nurse is contributing to the plan of care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following interventions should the nurse recommend?

Offer the client a bedpan every 2 hr.

Limit the client's daily fluid intake until he is no longer incontinent.

Request a prescription for an indwelling urinary catheter from the client's provider.

Ambulate the client to the bathroom every 30 min.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the best intervention, because offering the client a bedpan every 2 hr can help prevent urinary retention, bladder distension, and infection, which can worsen the incontinence. It can also help maintain the client's dignity and comfort, and promote bladder retraining.

Choice B reason: This is an incorrect intervention, because limiting the client's daily fluid intake can cause dehydration, constipation, and urinary tract infection, which can aggravate the incontinence. The client should drink adequate fluids, unless the provider instructs otherwise.

Choice C reason: This is an incorrect intervention, because requesting a prescription for an indwelling urinary catheter is not recommended for a client who has occasional urinary incontinence. An indwelling urinary catheter can increase the risk of infection, trauma, and obstruction, and interfere with the bladder function. The nurse should use other methods of bladder management, such as intermittent catheterization, external catheter, or incontinence pads.

Choice D reason: This is an incorrect intervention, because ambulating the client to the bathroom every 30 min can be unrealistic, exhausting, and unsafe for a client who has hemiplegia, or paralysis of one side of the body, due to a stroke. The client may not be able to walk or transfer without assistance, and may fall or injure themselves. The nurse should assess the client's mobility and ability to use the bathroom, and provide appropriate aids and support.

Urinary Retention | Urolife Clinic

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Correct Answer is D

Explanation

Choice A reason: This is a dangerous action, because recapping the needle on the syringe can increase the risk of needlestick injuries and bloodborne infections.

Choice B reason: This is an unnecessary action, because the client may be able to self-administer insulin injections with proper education and supervision.

Choice C reason: This is an inappropriate action, because the syringe should not be disposed of in the bathroom trash can, which is not a safe or sanitary place for sharps waste.

Choice D reason: This is the correct action, because placing the syringe in a puncture-proof disposal container can prevent accidental injuries and infections, and comply with the local regulations for sharps disposal.

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A. “Adults receive a natural immunity to herpes zoster from casual exposure to children who have had chickenpox.” B. “Herpes zoster is not contagious to individuals who received MMR vaccine as an infant.” C. “A client who has herpes zoster is not contagious if blisters are present on the skin.” D. “Herpes zoster is contagious to people who have never had chickenpox.”

Correct Answer is D

Explanation

Choice A reason: This is a false statement, because adults do not receive a natural immunity to herpes zoster from casual exposure to children who have had chickenpox. Herpes zoster is caused by the reactivation of the varicella-zoster virus, which remains dormant in the nerve cells after a primary infection with chickenpox.

Choice B reason: This is a false statement, because herpes zoster is not prevented by the MMR vaccine, which protects against measles, mumps, and rubella. Herpes zoster is prevented by the varicella vaccine, which is given separately from the MMR vaccine.

Choice C reason: This is a false statement, because a client who has herpes zoster is contagious if blisters are present on the skin. The blisters contain the varicella-zoster virus, which can be transmitted through direct contact or airborne droplets.

Choice D reason: This is the correct statement, because herpes zoster is contagious to people who have never had chickenpox. People who have never had chickenpox can contract the varicella-zoster virus from a person who has herpes zoster and develop chickenpox as a primary infection.

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A nurse is contributing to the plan of care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following interventions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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