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 C

Explanation

A. A document that the client signs indicating they wish to be an organ donor: This describes an organ donor card or organ donation consent form, not a living will. An organ donor card is a document indicating the individual's wish to donate organs after death to benefit others in need of organ transplants.

B. A medical order that outlines the client's wishes if cardiac or respiratory arrest occurs: This describes a do-not-resuscitate (DNR) order, which is a medical order indicating that the individual does not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. It is specific to resuscitation preferences and is different from a living will.

C. A witnessed legal document that describes the client's wishes regarding medical care if unable to speak: This is the correct description of a living will. A living will is a legal document that outlines a person's preferences regarding medical treatment and interventions in the event they become incapacitated and unable to communicate their wishes. It typically addresses preferences for life-sustaining treatments, such as mechanical ventilation, artificial nutrition and hydration, and other medical interventions.

D. A legal document that lists who gets the client's property & belongings before if they cannot communicate: This describes a last will and testament, which is a legal document that outlines how a person's property and assets should be distributed after their death. It does not address medical care preferences or interventions during the person's lifetime.

A. urinary leakage around the catheter." B. fecal matter from entering your bladder." C. injury to your urethra." D. the catheter from slipping out of your bladder."

Correct Answer is A

Explanation

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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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

The nurse is addressing a client's questions after admission to the hospital. What is an accurate description of a living will?

Correct Answer is C

Explanation

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:

Correct Answer is A

Explanation

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