An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?
Obtain a clean, voided urine specimen for analysis.
Evaluate the client's response to bladder training efforts.
Provide protective undergarments for the client.
Encourage increased fluid intake for 24 hours.
The Correct Answer is A
Choice A reason: Obtaining a urine specimen is essential for analyzing possible infections or other abnormalities that could be causing urinary incontinence.
Choice B reason: While evaluating the client's response to bladder training is important, it is not the first step before diagnosing the cause of new-onset incontinence.
Choice C reason: Providing protective undergarments may help manage symptoms but does not address the underlying cause of the incontinence.
Choice D reason: Encouraging increased fluid intake could potentially exacerbate incontinence symptoms and is not a diagnostic intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
The correct answer is: A. Teach the client to use an incentive spirometer every 2 hours while awake and E. Remove the urinary catheter as soon as possible and encourage voiding.
Choice A reason:
Teaching the client to use an incentive spirometer every 2 hours while awake helps prevent postoperative pulmonary complications such as pneumonia. This intervention promotes lung expansion and clears secretions, reducing the risk of infection.
Choice B reason:
Administering low molecular weight heparin as prescribed is important for preventing deep vein thrombosis (DVT) and pulmonary embolism, but it does not directly reduce the risk of infection.
Choice C reason:
Assessing the pain level and medicating as needed is crucial for patient comfort and mobility, but it does not directly address infection prevention. Effective pain management can indirectly support recovery by enabling better mobility and respiratory function.
Choice D reason:
Maintaining sequential compression devices while in bed is aimed at preventing DVT, not infections. These devices help improve blood circulation and reduce the risk of blood clots.
Choice E reason:
Removing the urinary catheter as soon as possible and encouraging voiding reduces the risk of catheter-associated urinary tract infections (CAUTIs). Prompt removal of the catheter minimizes the duration of exposure to potential pathogens, thereby reducing infection risk.
Correct Answer is C
Explanation
Choice A reason: Suggesting that delirium is often a sign of underlying mental illness and that institutionalization is necessary can be distressing and may not be accurate without further assessment.
Choice B reason: Stating that dementia due to Alzheimer's disease is often reversible even in the late stages is incorrect; Alzheimer's disease is a progressive condition with no current cure.
Choice C reason: Recognizing the possibility of delirium due to depression, which can be reversible, is a hopeful and constructive approach that encourages further evaluation and treatment options.
Choice D reason: Suggesting that symptoms of dementia are permanent because of age can be disheartening and does not consider the potential for reversible causes of cognitive impairment.
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