A nurse is preparing a client for a pelvic examination. Which of the following actions should the nurse take?

Assist the client to a prone position.

Ask the client to empty their bladder.

Instruct the client to douche.

Place the client’s arms over their head.

Answer and Explanation

The Correct Answer is B

Ask the client to empty their bladder.

This is because a full bladder can interfere with the pelvic examination and cause discomfort to the client. The nurse should also instruct the client to avoid douching, using tampons, vaginal medications, sprays, powders, birth control foam, cream, or jelly for at least 24 hours before the exam.

Choice A is wrong because the client should be placed in a lithotomy position, not a prone position, for a pelvic examination.

Choice C is wrong because douching can alter the normal vaginal flora and pH, and increase the risk of infection.

Choice D is wrong because placing the client’s arms over their head can tighten the abdominal muscles and make the examination more difficult. The nurse should ask the client to place their arms at their sides or across their chest.

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Correct Answer is D

Explanation

Dysrhythmia is an abnormal heart rhythm that can be a sign of severe lithium toxicity.

Lithium toxicity can occur when a person takes too much lithium, a mood- stabilizing medication used to treat bipolar disorder and major depressive disorder.

Choice A is wrong because hypoglycemia is not a symptom of lithium toxicity. Hypoglycemia is low blood sugar that can cause symptoms such as shakiness, sweating, hunger, and confusion.

Choice B is wrong because excess salivation is not a symptom of lithium toxicity. Excess salivation can be caused by various factors, such as infections, medications, or nerve damage.

Choice C is wrong because urinary retention is not a symptom of lithium toxicity. Urinary retention is the inability to empty the bladder completely, which can cause pain, discomfort, and infection. Lithium toxicity can actually cause increased urine output, not decreased.

Normal ranges for blood lithium levels are 0.6 to 1.2 mEq/L for maintenance therapy and 0.8 to 1.5 mEq/L for acute therapy. Levels above 1.5 mEq/L can cause mild to moderate toxicity, and levels above 2.0 mEq/L can cause severe toxicity. Levels above 3.0 mEq/L are considered a medical emergency.

A. “Record your urination times for 24 hours before beginning the program.” B. “Drink 4 liters of fluid between 6:00 a.m. and 8:00 p.m.” C. “Void every 2 hours while awake.” D. “Eliminate caffeine from your diet.”

Correct Answer is A

Explanation

This instruction helps the client to establish a baseline of their bladder function and identify their voiding patterns. It also helps the nurse to design an individualized bladder-training program for the client.

Choice B is wrong because drinking 4 liters of fluid between 6:00 a.m. and 8:00 p.m. is excessive and can increase the frequency and urgency of urination. The client should drink enough fluids to prevent dehydration and constipation, but avoid drinking large amounts at one time or before bedtime.

Choice C is wrong because voiding every 2 hours while awake is not a bladder- training technique, but a scheduled toilet trip. Bladder training requires following a fixed voiding schedule and delaying urination after feeling the urge to go. Voiding every 2 hours may not allow the bladder to fill sufficiently and may interfere with the goal of increasing the bladder capacity.

Choice D is wrong because eliminating caffeine from the diet is not a specific instruction for bladder training, but a general lifestyle strategy to ease bladder problems. Caffeine can irritate the bladder and act as a diuretic, which can increase urine production and frequency.

However, eliminating caffeine alone may not be enough to improve urinary incontinence.

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A nurse is preparing a client for a pelvic examination. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client at a follow-up visit who has been taking lithium therapy for bipolar disorder. Which of the following findings should indicate to the nurse that the client is experiencing lithium toxicity?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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