A nurse is providing teaching to a client who has stress incontinence. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

"Attempt to void every 2 hours."

"Perform Kegel exercises several times daily."

"Maintain a daily fluid intake of 1,000 to 1,200 mL/day."

"Take prescribed diuretics no later than 2000."

"Maintain optimal body weight for height."

Answer and Explanation

Correct Answer : A,B,E

Rationale:

A. "Attempt to void every 2 hours.": Scheduled voiding helps reduce the likelihood of bladder overfilling and decreases episodes of leakage, especially in stress incontinence where physical pressure causes urine loss.

B. "Perform Kegel exercises several times daily.": Kegel exercises strengthen the pelvic floor muscles, which support the bladder and urethra. Regular practice improves muscle tone and helps control urine leakage during activities like coughing or sneezing.

C. "Maintain a daily fluid intake of 1,000 to 1,200 mL/day.": Limiting fluids excessively can lead to concentrated urine and bladder irritation, increasing urgency and risk of infection. A moderate, well-balanced intake closer to 1,500–2,000 mL/day is generally recommended.

D. "Take prescribed diuretics no later than 2000.": While relevant for fluid management, it's not a direct or primary instruction specifically for treating or managing stress incontinence itself. Diuretics increase urine production, which could potentially worsen incontinence.

E. "Maintain optimal body weight for height.": Excess weight increases abdominal pressure on the bladder, worsening stress incontinence. Achieving and maintaining a healthy weight can reduce symptoms and support pelvic muscle strength.

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Correct Answer is D

Explanation

Rationale:

A. Use passive listening techniques during conflict resolution: Passive listening involves minimal engagement and can lead to misunderstandings or missed key concerns. Active listening is more effective in conflict resolution as it validates feelings and clarifies perspectives.

B. Ask closed-ended questions about the conflict: Closed-ended questions limit the depth of responses and may not fully uncover the underlying issues. Open-ended questions encourage dialogue and help reveal the root causes of conflict more effectively.

C. Ensure each individual can respond defensively about the conflict: Allowing or encouraging defensive responses can escalate tension and hinder resolution. A nonjudgmental and respectful environment promotes open communication and constructive problem-solving.

D. Gather individual information regarding the conflict: Collecting information from each party separately allows the nurse manager to understand different perspectives, identify miscommunications, and develop a balanced and informed approach to resolving the conflict.

A. Obtain a 12-lead ECG for the client. B. Have the client stop walking and sit down. C. Administer sublingual nitroglycerin to the client. D. Measure the client's vital signs.

Correct Answer is B

Explanation

Rationale:

A. Obtain a 12-lead ECG for the client: An ECG is important for diagnosing myocardial ischemia or infarction, but it is not the immediate first step. The priority is to stop activity and reduce myocardial oxygen demand before further diagnostics.

B. Have the client stop walking and sit down: Angina is often triggered by physical exertion. Stopping activity and sitting down reduces oxygen demand on the heart, alleviates symptoms, and prevents further ischemia. This is the most immediate and essential first action.

C. Administer sublingual nitroglycerin to the client: Nitroglycerin helps relieve anginal pain by dilating coronary arteries, but it should be given after the client has stopped activity and rested. Administering it while the client is still active may not be effective or safe.

D. Measure the client's vital signs: While vital signs are important for assessing the client’s current status, the priority is to stop exertion, which is likely contributing to myocardial oxygen imbalance. Assessment follows immediate symptom relief measures.

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A nurse is providing teaching to a client who has stress incontinence. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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