Your second older adult female client has been experiencing some problems with urinary incontinence. You suggest that she document which of the following in a “bladder/voiding diary”? (Select all that apply.)

Difficulty starting or stopping the urinary stream

The character of the urine

Ability to reach a toilet and use it

Whether she had a bowel movement at the same time

The amount and timing of fluid intake and urine output

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason:

It is important for the client to document any difficulty starting or stopping the urinary stream as this can indicate potential issues with bladder function or muscle control.

Choice B reason:

Documenting the character of the urine, such as color and odor, can provide valuable insights into potential underlying health issues, such as dehydration or urinary tract infections.

Choice C reason:

The ability to reach a toilet and use it is crucial information as it helps in understanding the client's mobility and accessibility to restroom facilities, which can impact her urinary patterns.

Choice D reason:

Although not listed, it's essential to note that having a bowel movement at the same time can also provide insights into potential underlying issues and patterns related to urinary incontinence.

Choice E reason:

The amount and timing of fluid intake and urine output are imperative to track as they can reveal patterns and potential triggers for urinary incontinence, aiding in the development of an effective management plan.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice A reason: Isolated systolic hypertension is not a result of end-organ damage from chronic hypertension, but rather a risk factor for it. Isolated systolic hypertension is a condition where the systolic blood pressure is elevated (>140 mmHg) while the diastolic blood pressure is normal (<90 mmHg). It is common in older adults due to the stiffening of the arteries, and can increase the risk of cardiovascular and cerebrovascular events.

Choice B reason: Atrial fibrillation is a result of end-organ damage from chronic hypertension. Atrial fibrillation is an irregular and often rapid heart rate that can cause poor blood flow and increase the risk of stroke and heart failure. Chronic hypertension can damage the heart muscle and the electrical system of the heart, leading to atrial fibrillation.

Choice C reason: Renal insufficiency is a result of end-organ damage from chronic hypertension. Renal insufficiency is a condition where the kidneys are unable to filter waste and fluid from the blood adequately. Chronic hypertension can damage the blood vessels and the nephrons of the kidneys, leading to renal insufficiency.

Choice D reason: Stroke is a result of end-organ damage from chronic hypertension. Stroke is a sudden interruption of blood supply to the brain, causing brain cell death and neurological deficits. Chronic hypertension can damage the blood vessels in the brain, making them prone to rupture (hemorrhagic stroke) or blockage (ischemic stroke).

Choice E reason: Cardiac disease is a result of end-organ damage from chronic hypertension. Cardiac disease is a broad term that encompasses various disorders of the heart, such as coronary artery disease, heart attack, heart failure, and cardiomyopathy. Chronic hypertension can damage the heart by increasing the workload and the oxygen demand of the heart, causing the heart to enlarge and weaken over time.

A. Turn immobile clients every 2 hours off bony prominences. B. Use lift or draw sheets to move clients in bed. C. Keep the moist D. Ensure that your client maintains a healthy nutritional status. E. Apply pressure-relieving devices to vulnerable areas.

Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason: Turning immobile clients every 2 hours off bony prominences can reduce the pressure and friction that can cause skin breakdown and ulcer formation.

Choice B reason: Using lift or draw sheets to move clients in bed can prevent dragging or pulling the skin, which can cause shear and damage the underlying tissue.

Choice C reason: Keeping the skin moist is not a correct way to prevent pressure ulcers. Moisture can weaken the skin and make it more prone to injury. The skin should be kept dry and clean, and moisturized if needed.

Choice D reason: Ensuring that your client maintains a healthy nutritional status can promote wound healing and prevent infection. Adequate protein, calories, vitamins, and minerals are essential for skin integrity and tissue repair.

Choice E reason: Applying pressure-relieving devices to vulnerable areas can distribute the pressure and protect the skin from damage. Examples of pressure-relieving devices are foam pads, air mattresses, or cushions.

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Your second older adult female client has been experiencing some problems with urinary incontinence. You suggest that she document which of the following in a “bladder/voiding diary”? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which are potential results of end-organ damage from chronic hypertension? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

Pressure ulcers are defined as an injury to the skin and/or underlying tissue resulting from pressure or in combination with shear, usually over a bony prominence. As a nurse, what do you know you must do to prevent pressure ulcers? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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