The client asks the nurse "Why is it necessary to secure the indwelling urinary catheter to my thigh?" The nurse's best response would be. "It is Important to prevent:

urinary leakage around the catheter."

fecal matter from entering your bladder."

injury to your urethra."

the catheter from slipping out of your bladder."

Answer and Explanation

The Correct Answer is A

A. Urinary leakage around the catheter: Securing the indwelling urinary catheter to the thigh helps prevent urinary leakage around the catheter site. Catheter movement or dislodgement can lead to leakage of urine around the catheter, which can cause skin irritation, increase the risk of urinary tract infections (UTIs), and compromise hygiene. Securing the catheter to the thigh helps maintain its position and prevents movement that could contribute to leakage.

B. Fecal matter from entering your bladder: While securing the catheter can help maintain proper positioning and prevent movement, its primary purpose is not to prevent fecal matter from entering the bladder. Indwelling urinary catheters are inserted into the bladder through the urethra, and proper catheter placement and hygiene practices are essential for preventing contamination of the urinary tract with fecal matter.

C. Injury to your urethra: Securing the catheter to the thigh does not directly prevent injury to the urethra. Proper insertion technique and appropriate catheter size selection are more critical for preventing urethral injury during catheterization. Securing the catheter primarily aims to maintain its position and prevent movement that could potentially cause discomfort or complications.

D. The catheter from slipping out of your bladder: While securing the catheter can help prevent inadvertent dislodgement, its primary purpose is not to prevent the catheter from slipping out of the bladder. Proper catheter securement techniques, including securing it to the thigh or using catheter stabilization devices, help maintain the catheter's position and minimize movement, reducing the risk of accidental removal.

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Correct Answer is D

Explanation

A. Type of diet: While the type of diet may be relevant to the overall health and well-being of the older adult client, it may not directly contribute to understanding the change in mental status. While nutritional deficiencies or imbalances could potentially impact mental status, other factors are more immediately relevant to assessing the change in mental status.

B. Cultural considerations: Cultural considerations are important in providing holistic care to the older adult client, but they may not directly contribute to understanding the change in mental status. Cultural factors could influence communication styles, beliefs about health and illness, and preferences for care, but they may not be the primary focus when assessing a change in mental status.

C. Gender: Gender may have some relevance to the overall health and well-being of the older adult client, but it may not directly contribute to understanding the change in mental status. While certain gender-related factors, such as hormonal changes or gender-specific health conditions, could potentially impact mental health, they may not be the primary focus when assessing a change in mental status.

D. History of onset: This represents a critical thinking approach because understanding the history of onset of the change in mental status is essential for identifying potential causes and determining appropriate interventions. The timing and circumstances surrounding the onset of the change can provide valuable information about possible contributing factors, such as recent illnesses, medication changes, trauma, or environmental changes. By gathering information about the history of onset, the nurse can engage in critical thinking to formulate hypotheses, prioritize assessments, and develop a plan of care tailored to the client's needs.

A. the person experiencing the pain is the authority about the pain. B. administering analgesics for pain will eventually lead to addiction. C. behavioral signs are always congruent with statements about pain. D. the extent of pain is directly related to the amount of tissue damage.

Correct Answer is A

Explanation

A. The person experiencing the pain is the authority about the pain: This is the most important principle to recognize when caring for a patient in pain. Pain is a subjective experience, and the individual experiencing it is the best authority on their pain. Nurses should listen to and respect the patient's descriptions and assessments of their pain, as they are the ones experiencing it firsthand. This principle underscores the importance of patient-centered care and empowers patients to participate in decisions about pain management.

B. Administering analgesics for pain will eventually lead to addiction: While concerns about addiction are important to consider when administering analgesics, this statement is not the most important principle to recognize when caring for a patient in pain. Fear of addiction should not overshadow the patient's right to adequate pain relief. Nurses should prioritize effective pain management while also considering factors such as the patient's history of substance use and monitoring for signs of misuse or addiction.

C. Behavioral signs are always congruent with statements about pain: While behavioral signs can provide valuable information about a patient's pain experience, they may not always be congruent with verbal statements about pain. Some patients may exhibit stoic behaviors despite experiencing significant pain, while others may express distress more visibly. Nurses should consider both verbal and non-verbal cues when assessing pain and tailor interventions accordingly.

D. The extent of pain is directly related to the amount of tissue damage: While pain often accompanies tissue damage or injury, the extent of pain experienced by an individual is influenced by various factors beyond just tissue damage. Pain perception is subjective and can be influenced by factors such as psychological, emotional, cultural, and social factors. Therefore, pain intensity may not always directly correlate with the amount of tissue damage present.

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The client asks the nurse "Why is it necessary to secure the indwelling urinary catheter to my thigh?" The nurse's best response would be. "It is Important to prevent:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client experiences a change in mental status. Which assessment finding represents a critical thinking approach?

Correct Answer is D

Explanation

When caring for a patient in pain, the most important principle that the nurse must recognize is that:

Correct Answer is A

Explanation

The nurse is assessing a 66-year-old client who reports having a fever and feeling weak and dizzy with nausea and vomiting for three days. The nurse observes a dry tongue and oral mucosa, and concentrated urine. To best assess the client's fluid status, which parameter(s) should the nurse check?

The nurse makes an error while documenting in the client's chart. The nurse should:

The nurse assesses a client with a history of deficient fluid volume. What are the most accurate findings for this fluid volume status? (SELECT ALL THAT APPLY)

What meal option should a nurse choose for a client with fluid volume excess who has been placed on a low-sodium diet?

What is the best description for the professional value of social justice? The nurse…

The nurse assesses a client admitted with a history of vomiting and diarrhea for 5 days. Which laboratory value validates the symptoms of the client?

The nurse is performing an admission assessment on a client who has chronic pain. Which statement made by the client causes the most concern?

The nurse is caring for a client who trips and falls over a trash can left in the path to the bathroom. Which is part of an appropriate charting entry?