A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first?

Determine the client's pattern for voiding

Discourage intake of carbonated beverages.

Assist the client with relaxation techniques.

Offer toileting opportunities every 1 to 2 hr.

Answer and Explanation

The Correct Answer is A

Explanation: The first step in bladder training is to assess the client's baseline bladder function and identify factors that may affect it, such as fluid intake, medications, or mobility issues. The other interventions are part of bladder training but should be implemented after assessment.

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Correct Answer is B

Explanation

The correct answer is choice B. Nontender, protruding abdomen.

Choice A rationale:

Natural loss of deciduous teeth typically begins around the age of 6 years, not at 2 years. At 2 years old, toddlers are still in the process of getting their primary teeth.

Choice B rationale:

A nontender, protruding abdomen is a normal finding in toddlers due to their developing abdominal muscles and the typical posture of a toddler.

Choice C rationale:

By the age of 2, a child’s head circumference should no longer exceed their chest circumference. This is a characteristic of infants, not toddlers.

Choice D rationale:

Palpable fontanels are expected in infants. By the age of 2, the anterior fontanel should have closed, making it non-palpable.

A. The AP inserts the probe with a straightforward motion. B. The AP positions the client facing her. C. The AP pulls the pinna up and back D. The AP points the probe posteriorly.

Correct Answer is C

Explanation

The correct answer is choice C. The AP pulls the pinna up and back.

Choice A rationale:

Inserting the probe with a straightforward motion is not sufficient to ensure an accurate reading. Proper positioning of the ear canal is necessary to get an accurate tympanic temperature.

Choice B rationale:

Positioning the client facing the AP is not relevant to the accuracy of the tympanic temperature measurement. The focus should be on the correct technique for inserting the probe.

Choice C rationale:

Pulling the pinna up and back is the correct technique for adults and children over 3 years old. This action straightens the ear canal, allowing for an accurate temperature reading.

Choice D rationale:

Pointing the probe posteriorly is not a standard guideline for taking a tympanic temperature. The probe should be aimed towards the eardrum for an accurate measurement.

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A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?

Correct Answer is C

Explanation

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