An older adult client residing in a long-term care facility has become disoriented and suddenly develops 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.

Place a protective undergarment on the client.

Encourage increased fluid intake for 24 hours.

Answer and Explanation

The Correct Answer is A

A.   Urinary incontinence in an older adult can be a symptom of various underlying conditions, such as urinary tract infections, dehydration, or cognitive impairment. Obtaining a urine specimen for analysis can help to identify the underlying cause of the incontinence and guide appropriate treatment.
B.   Bladder training is a technique used to improve bladder control and reduce incontinence. However, it's not appropriate to evaluate the client's response to bladder training efforts when they have suddenly become disoriented and developed incontinence. This suggests a potential underlying medical condition that needs to be addressed first.
C.   While protective undergarments can be helpful in managing incontinence, they do not address the underlying cause of the problem. It's important to identify and treat the underlying condition to improve the client's quality of life and prevent complications.
D.   While dehydration can sometimes contribute to incontinence, it's not appropriate to increase fluid intake in a client who has suddenly become disoriented. This could worsen their condition, especially if they have cognitive impairment or other underlying medical conditions.

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Correct Answer is D

Explanation

A. While establishing a mental status baseline is important for assessing the client's overall neurological condition and any potential changes in consciousness or cognition, it is not the immediate priority in this case.
B. Inserting a urinary catheter might be necessary for monitoring urine output, especially if there are concerns about fluid balance or kidney function. However, it is not the immediate priority in this scenario unless there are signs of urinary retention or output issues.
C. Checking the accuracy of the medication list is important for understanding the client's current treatment regimen and any possible drug interactions or errors. However, this action does not directly address the urgent symptoms of fever, nausea, vomiting, and blurred vision, which could be indicative of a more immediate medical issue.
D. Given the client’s history of insulin-dependent diabetes mellitus and the presenting symptoms, obtaining a capillary blood glucose level is the most critical and immediate intervention. The symptoms of fever, nausea, vomiting, and blurred vision can be associated with hyperglycemia (high blood glucose) or hypoglycemia (low blood glucose).

A. Advise the client that high doses of fish oils can increase the risk for bleeding. B. Reassure the client that eating large amounts of fish products is heart-healthy. C. Encourage the client to increase the dose unless GI symptoms develop. O D. Teach the client that all types of oils increase cholesterol and triglycerides.

Correct Answer is A

Explanation

A. High doses of fish oil can indeed increase the risk of bleeding, particularly because fish oil has anticoagulant properties that can interfere with blood clotting. This risk is especially significant if the client is also taking other anticoagulant or antiplatelet medications.
B. While it is true that fish can be heart-healthy due to its omega-3 fatty acids, this statement does not fully address the concerns about the safety of high doses of fish oil supplements. Eating fish in moderate amounts is beneficial, but the focus here is on the effects of large doses of fish oil supplements, not just consuming fish. The safety of high doses should be considered separately.
C. Encouraging the client to increase the dose of fish oil is not appropriate without considering potential side effects and risks. High doses of fish oil can lead to gastrointestinal symptoms like nausea, diarrhea, and indigestion.
D. Not all types of oils increase cholesterol and triglycerides. For instance, omega-3 fatty acids found in fish oil can actually help lower triglyceride levels and may have a positive effect on cholesterol levels.

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An older adult client residing in a long-term care facility has become disoriented and suddenly develops urinary incontinence. Which intervention should the nurse implement?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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