Which nursing action is the priority intervention for a client diagnosed with total urinary incontinence?
Toileting routine.
Kegel exercises.
Surgery.
Anticholinergic drug therapy.
The Correct Answer is A
A toileting routine is the priority intervention for a client diagnosed with total urinary incontinence because it helps to prevent skin breakdown, infection, and odor. It also promotes dignity and comfort for the client.
Choice B. Kegel exercises are wrong because they are not effective for total urinary incontinence, which is the complete loss of bladder control. Kegel exercises are more useful for stress or urge urinary incontinence, which are caused by weak pelvic floor muscles.
Choice C. Surgery is wrong because it is not a priority intervention for total urinary incontinence.
Surgery may be considered a last resort option if other conservative measures fail to improve the condition. Surgery may also have risks and complications that need to be weighed against the benefits.
Choice D. Anticholinergic drug therapy is wrong because it is not a priority intervention for total urinary incontinence.
Anticholinergic drugs are used to treat overactive bladder or urge urinary incontinence, which are caused by involuntary bladder contractions. Anticholinergic drugs may have side effects such as dry mouth, constipation, blurred vision, and confusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because coughing can indicate aspiration of the feeding into the lungs, which can lead to pneumonia and other serious complications. Aspiration is reported in up to 89% of patients receiving nasogastric tube feeding.
Therefore, the nurse should prioritize assessing the client for signs of aspiration and ensuring proper tube placement.
Choice B is wrong because mild abdominal cramps are a common side effect of nasogastric tube feeding and do not require immediate intervention unless they are severe or persistent.
Choice C is wrong because high-pitched bowel sounds are normal and indicate peristalsis and digestion.
They do not indicate a problem with the tube feeding.
Choice D is wrong because one to two soft bowel movements per day are desirable and indicate adequate nutrition and hydration.
They do not indicate a problem with the tube feeding.
Normal ranges for gastric residual volume are less than 200 mL for adults and less than 100 mL for children. Normal ranges for pH of gastric aspirate are 1 to 5.
Correct Answer is B
Explanation
My spouse will just have to put up with any new irritability. This statement indicates that the client requires further educational reinforcement about the medication because phenelzine is an antidepressant that should improve the mood and reduce irritability. The client may also need to be assessed for possible adverse effects of phenelzine, such as agitation, insomnia, or hypomania.
Choice A is wrong because it is a correct statement. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with foods that contain tyramine, such as cheese and caffeine, and cause a hypertensive crisis.
The client should avoid excessive amounts of these foods while taking phenelzine.
Choice C is wrong because it is also a correct statement. Phenelzine can cause orthostatic hypotension, which is a drop in blood pressure when changing positions.
The client should change positions slowly, as dizziness may occur.
Choice D is wrong because it is partially correct. Phenelzine can cause headaches, which may be a sign of a hypertensive crisis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.