What would be the best nursing action to facilitate bladder continence for the client who is cognitively impaired?

Offer toileting reminders every 2 hours

Provide clothing that is easy to manipulate

Explain the need to call for the nurse to help with toileting

Encourage avoidance of fluids between meals

Answer and Explanation

The Correct Answer is A

A. Offer toileting reminders every 2 hours: This is the best nursing action because it helps prevent urinary incontinence by prompting the client to use the bathroom regularly. Clients with cognitive impairment may have difficulty recognizing the need to void or remembering when to do so. Providing frequent reminders helps maintain bladder continence and reduces the risk of accidents.

B. Provide clothing that is easy to manipulate: While providing clothing that is easy to manipulate can be helpful for clients with cognitive impairment to independently manage toileting, it does not directly address the issue of facilitating bladder continence. Easy-to-manipulate clothing may assist with toileting independence but does not address the need for regular voiding to prevent urinary incontinence.

C. Explain the need to call for the nurse to help with toileting: While educating the client about when to seek assistance for toileting needs is important, it may not be sufficient for facilitating bladder continence in a client with cognitive impairment. Clients may still have difficulty recognizing the need to void or remembering to call for assistance, making frequent reminders more effective in promoting continence.

D. Encourage avoidance of fluids between meals: Encouraging avoidance of fluids between meals is not an appropriate strategy for promoting bladder continence. Restricting fluids can lead to dehydration and other health complications. Maintaining adequate hydration is essential for overall health, and clients should be encouraged to drink fluids regularly throughout the day. Additionally, restricting fluids does not address the underlying issue of cognitive impairment affecting toileting behaviors.

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Correct Answer is D

Explanation

A. Paternalism: Paternalism refers to the healthcare provider making decisions on behalf of the client without their input or consent, typically for the client's perceived benefit. In this scenario, the nurse is not making decisions for the client but rather honoring an agreement to reassess pain after interventions.

B. Confidentiality: Confidentiality refers to maintaining the privacy and security of client information. It does not directly relate to the nurse's commitment to follow through on a verbal contract with the client regarding pain reassessment.

C. Responsibility: Responsibility involves being accountable for one's actions and obligations in providing care to clients. While responsibility is important in nursing practice, it does not specifically address the nurse's commitment to fulfill a verbal contract with the client regarding pain reassessment.

D. Fidelity: Fidelity, also known as loyalty or faithfulness, pertains to the nurse's obligation to uphold commitments made to clients. In this scenario, the nurse is demonstrating fidelity by returning within the agreed-upon time frame to evaluate the effectiveness of pain interventions as promised to the client. This principle emphasizes the importance of keeping promises and honoring agreements made with clients, thereby building trust and promoting ethical practice in nursing.

A. hypovolemic shock. B. hemodilution. C. excess fluid volume. D. deficient fluid volume.

Correct Answer is C

Explanation

A. Hypovolemic shock: Hypovolemic shock is characterized by decreased blood volume, leading to inadequate tissue perfusion and oxygen delivery. The clinical findings described, such as sudden weight gain, bounding pulses, and elevated blood pressure, are not consistent with hypovolemic shock, which typically presents with hypotension, weak pulses, and signs of poor tissue perfusion.

B. Hemodilution: Hemodilution refers to a decrease in the concentration of blood components due to an increase in plasma volume. While weight gain may result from hemodilution, other clinical findings described, such as bounding pulses and elevated blood pressure, are not indicative of hemodilution.

C. Excess fluid volume: This is the correct answer. The sudden weight gain, bounding pulses, and elevated blood pressure suggest an excess of fluid volume. Bounding pulses can occur due to increased stroke volume from the heart pumping against increased volume, while elevated blood pressure can result from the increased fluid volume increasing cardiac output. Sudden weight gain is often attributed to fluid retention.

D. Deficient fluid volume: Deficient fluid volume, also known as dehydration, is characterized by insufficient fluid in the body. The clinical findings described, such as sudden weight gain and elevated blood pressure, are not consistent with deficient fluid volume. In dehydration, blood pressure tends to decrease rather than increase.

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What would be the best nursing action to facilitate bladder continence for the client who is cognitively impaired?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse verbally contracts with a client to reassess their pain level after repositioning and an analgesic is given. The nurse returns within 60 minutes to evaluate effectiveness of the interventions. What ethical principle does this represent?

Correct Answer is D

Explanation

The nurse is caring for a client who presents with a sudden 5 lb. (2.3 kg) weight gain, bounding pulses, and a blood pressure of 174/94. These clinical findings are indicative of:

Correct Answer is C

Explanation

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