A nurse is planning care for a client who has renal stones and a urinary catheter in place.
Which of the following interventions should the nurse include in the plan of care?

Maintain the client on bed rest.

Strain the client's urine through a mesh filter.

Encourage fluid intake of 1500 mL/day.

Clamp the urinary catheter every 2 hr.

Answer and Explanation

The Correct Answer is B

a. Maintain the client on bed rest: While rest may be indicated in some cases, it is not a specific intervention for managing renal stones with a urinary catheter.

b. Strain the client's urine through a mesh filter: Straining urine is essential to collect any stones that may have passed, allowing for analysis and identification.

c. Encourage fluid intake of 1500 mL/day: Adequate fluid intake is crucial to prevent stone formation, but the amount may vary depending on the client's specific needs and condition.

d. Clamp the urinary catheter every 2 hr: Clamping the urinary catheter is not a standard

intervention for managing renal stones. Straining the urine for stone collection is a more relevant intervention.

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Correct Answer is A

Explanation

a. Postictal phase: The postictal phase refers to the period following a seizure during which the individual may be drowsy, confused, or sleepy. This phase can last varying amounts of time.

b. Presence of absence seizures: Absence seizures are characterized by brief episodes of staring and altered consciousness but do not typically have a postictal phase with prolonged sleepiness.

c. Aura phase: The aura phase occurs before a seizure and involves sensory or perceptual changes that serve as a warning sign. It does not describe the postictal state.

d. Presence of automatisms: Automatisms are repetitive, non-purposeful movements that can occur during certain types of seizures but do not describe the postictal state of sleepiness.

A. Circular, erythematous patches on the scalp. B. Recent exposure to poison ivy. C. Scaling and redness between the toes. D. A recent prescription for an antiseizure medication.

Correct Answer is C

Explanation

a. Circular, erythematous patches on the scalp: This description is more indicative of tinea capitis, a fungal infection affecting the scalp.

b. Recent exposure to poison ivy: Poison ivy exposure would result in a contact dermatitis rash, not tinea pedis.

c. Scaling and redness between the toes: Tinea pedis, also known as athlete's foot, commonly presents with scaling, redness, and itching between the toes.

d. A recent prescription for an antiseizure medication: Antiseizure medications are not associated with the development of tinea pedis.

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A nurse is planning care for a client who has renal stones and a urinary catheter in place.
Which of the following interventions should the nurse include in the plan of care?