The nurse is providing education to a client who is returning home with an indwelling urinary catheter after having a transurethral resection of the prostate (TURP). Which statement made by the client demonstrates a need for the nurse to clarify the instructions?

Start pelvic floor exercises.

Report fever or chills.

Increase fluid intake to help with hydration.

Tape urinary catheter securely to the thigh.

Answer and Explanation

The Correct Answer is A

Choice A reason: Starting pelvic floor exercises might be beneficial in the long term for improving urinary control after TURP. However, immediately following the surgery and while the indwelling catheter is in place, it may not be the appropriate time to begin these exercises. The nurse should clarify when and how to start pelvic floor exercises.

Choice B reason: Reporting fever or chills is crucial because these symptoms could indicate an infection, which requires prompt medical attention. This statement reflects an understanding of important post-operative care instructions and does not need clarification.

Choice C reason: Increasing fluid intake to help with hydration is important for clients with a urinary catheter. Adequate hydration helps flush the urinary system and prevent complications such as urinary tract infections. This statement does not need clarification.

Choice D reason: Taping the urinary catheter securely to the thigh helps prevent tension on the catheter and reduces the risk of accidental dislodgement or trauma. This instruction is correct and does not need clarification.

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Correct Answer is D

Explanation

Choice A reason: Reducing the client's interaction with others during the day can potentially isolate the client and exacerbate feelings of agitation and confusion. Social interaction is important for cognitive stimulation and emotional well-being, even for clients with Alzheimer's disease.

Choice B reason: Awaking the client for reality checks every 4 hours at night can disrupt the client's sleep pattern, leading to increased agitation and confusion. Proper rest is crucial for clients with Alzheimer's disease to help manage their symptoms effectively.

Choice C reason: Clarifying reality with the client about delusional thoughts can sometimes increase agitation if not done sensitively. Clients with Alzheimer's disease may not respond well to direct confrontation about their delusions. It is often more effective to use techniques that do not directly challenge their perception of reality.

Choice D reason: Using distraction and therapeutic communication skills is the best approach. This strategy helps redirect the client's attention to a different, more calming activity, which can reduce agitation. Therapeutic communication involves understanding and validating the client's feelings while gently guiding them towards a more positive state. This approach respects the client's experience and provides support without escalating their agitation.

A. Effectively manage pain, discomfort, and diarrhea. B. Ensure careful fluid and electrolyte balance. C. Reduce number and severity of acute exacerbations. D. Maintain a diet that is high in fibber content. I. In planning care for a client with chronic ulcerative colitis, which long-term goal is most important for the nurse to include?

Correct Answer is C

Explanation

Choice A reason: Effectively managing pain, discomfort, and diarrhea is important for the client’s quality of life, but it does not address the long-term goal of preventing disease progression and complications.

Choice B reason: Ensuring careful fluid and electrolyte balance is critical, especially during acute exacerbations, but it is more of an immediate concern rather than a long-term goal.

Choice C reason: Reducing the number and severity of acute exacerbations is the most important long-term goal for clients with chronic ulcerative colitis. This goal focuses on maintaining remission, preventing complications, and improving overall prognosis by minimizing flare-ups.

Choice D reason: Maintaining a diet that is high in fibber content can be beneficial for overall health but may not always be suitable for clients with ulcerative colitis, especially during flare-ups. It is not the most critical long-term goal for managing the condition.

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The nurse is providing education to a client who is returning home with an indwelling urinary catheter after having a transurethral resection of the prostate (TURP). Which statement made by the client demonstrates a need for the nurse to clarify the instructions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for an older adult client with Alzheimer's disease who becomes increasingly agitated and is speaking to someone who is not visible to the nurse. Which action should the nurse implement?

Correct Answer is D

Explanation

In planning care for a client with chronic ulcerative colitis, which long-term goal is most important for the nurse to include?

Correct Answer is C

Explanation

The nurse is assessing a client who has left ventricular heart failure. Which assessment finding is this client most likely to exhibit?

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