The nurse is planning care for the elimination needs of a group of clients. The nurse determines a bedpan will be needed for which client?

An older adult with left sided weakness.

An adult client with enuresis

An adult client with polyuria.

An older adult with a right hip fracture.

Answer and Explanation

The Correct Answer is D

A. An older adult with left sided weakness: This client may require assistance to ambulate or use a bedside commode, but depending on strength and stability, they might still be able to use the toilet with support rather than needing a bedpan.

B. An adult client with enuresis: Enuresis refers to involuntary urination, often during sleep. This condition is not an indication for a bedpan, as the focus would be on continence management rather than assisted toileting.

C. An adult client with polyuria: Increased urine output due to polyuria does not necessarily impair mobility. Unless the client is immobile, they can use a toilet or commode rather than a bedpan.

D. An older adult with a right hip fracture: A hip fracture significantly impairs mobility and weight-bearing ability, making it unsafe to ambulate to the bathroom or commode. A bedpan is typically required until mobility is restored or stabilized.

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Correct Answer is []

Explanation

Potential Condition:
Functional incontinence: This occurs when a person is continent but unable to reach the toilet due to physical limitations, environmental barriers, or cognitive impairment. In this case, the client is physically weak and could not access the bathroom or call for help in time.

Actions to Take:
Secure the call bell so it is within reach: This empowers the client to request assistance promptly, helping to prevent further episodes of incontinence.
Create a toilet training program: Scheduled toileting or prompted voiding assists in managing incontinence related to functional limitations.

Parameters to Monitor:
Episodes of incontinence: Tracking frequency helps assess if interventions are reducing the number of episodes.
Skin integrity: Incontinence increases the risk for skin breakdown, especially in older adults with limited mobility.

Incorrect Potential Conditions:

Overflow urinary incontinence: Involves dribbling due to bladder overdistension, typically from obstruction or weak detrusor muscles—not consistent with this client’s symptoms.

Reflex urinary incontinence: Related to neurological impairment; the client shows no signs of spinal cord injury or neurological disease.

Urge incontinence: Involves sudden urgency with loss of urine before reaching a toilet; not reported by the client.

A. Proceed with teaching the client how to walk with the crutches. B. Confer with the physical therapist for correct crutch size. C. Assess the client for signs of diminished circulation in the hands D. Ask the client to sit down while the crutch length is adjusted

Correct Answer is A

Explanation

A. Proceed with teaching the client how to walk with the crutches: A space of about two to three finger-widths between the top of the crutch and the axilla is the correct fit. This prevents pressure on the axillary nerves and allows for safe use, so it is appropriate to move forward with ambulation teaching.

B. Confer with the physical therapist for correct crutch size: Consultation is unnecessary at this point since the crutches appear to be appropriately sized based on the standard axillary gap.

C. Assess the client for signs of diminished circulation in the hands: While monitoring circulation is important, there is no indication of a problem at this stage. The crutch fit appears correct, so circulation is unlikely to be compromised.

D. Ask the client to sit down while the crutch length is adjusted: Adjustment is not needed if the crutch height already allows the standard three finger-width space from the axilla, indicating proper fit.

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The nurse is planning care for the elimination needs of a group of clients. The nurse determines a bedpan will be needed for which client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger-widths between the top of the crutch and the client's axilla. Which action should the nurse take?

Correct Answer is A

Explanation

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In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

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While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?