Some things that you, as the nurse, might teach your client to help control urinary incontinence include which of the following (Select all that apply)?

Choice A reason: Measure the blood pressure in sitting and standing positions is not the next action by the nurse, as it is not relevant to the situation. The nurse should compare the blood pressure readings from both arms, not from different postures.

Choice B reason: Measure the blood pressure in the left arm is the next action by the nurse, as it can help determine if the high blood pressure is consistent or isolated to one arm. A difference of more than 10 mm Hg between the arms may indicate a vascular problem, such as atherosclerosis, aneurysm, or coarctation of the aorta.

Choice C reason: Document the findings in the medical record; elevated blood pressures are normal in older adults is not the next action by the nurse, as it is inaccurate and irresponsible. The nurse should not assume that elevated blood pressures are normal in older adults, as they may indicate hypertension, which is a risk factor for cardiovascular disease, stroke, and kidney damage. The nurse should also not document the findings without further assessment and intervention.

Choice D reason: Immediately contact the medical provider is not the next action by the nurse, as it may be premature and unnecessary. The nurse should first confirm the accuracy of the blood pressure readings by measuring the blood pressure in the left arm and checking the calibration of the device. The nurse should also consider other factors that may affect the blood pressure, such as pain, stress, caffeine, or medication.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the next action by the nurse.

Choice A reason: Having stable vital signs does not necessarily mean that the client is not experiencing pain. Vital signs can be affected by various factors, such as medications, stress, or emotions, and may not reflect the true level of pain.

Choice B reason: Holding abdomen tightly is a possible sign of pain, especially if the client had abdominal surgery or has a condition that affects the digestive system. The client may be guarding the painful area or trying to relieve the discomfort.

Choice C reason: Not verbalizing is not a reliable indicator of pain, especially for clients with dementia who may have difficulty communicating or expressing their feelings. The nurse should look for other cues, such as facial expressions, body language, or behavioral changes, to assess the client's pain.

Choice D reason: Moving during sleep is not a specific sign of pain, and may be normal for some clients. However, if the client is restless, agitated, or moaning during sleep, it may indicate that the client is in pain and needs intervention.