Solutions - Chapter 48 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. Which of the following behaviours indicates that the client on a bladder training program has met the expected outcomes? Select all that apply.
1.  Voids each time there is an urge.
2.  Practices slow, deep breathing until the urge decreases.
3.  Uses adult diapers, for “just in case.”
4.  Drinks citrus juices and carbonated beverages.
5.  Performs pelvic muscle exercises.
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1ACT. Considering Mr. Baker’s history and assessment data, what other physical conditions could explain his symptoms?
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1TYK. The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following?
1.  The bladder distends and its capacity increases.
2.  Older adults ignore the need to void.
3.  Urine becomes more concentrated.
4.  The amount of urine retained after voiding increases.
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2ACT. The primary care provider has recommended surgery. What assumptions will the nurse need to validate in helping prepare Mr. and Mrs. Baker for this surgery?
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2TYK. During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply.
1.  Perineal skin irritation
2.  Fluid intake of less than 1,500 midday
3.  History of antihistamine intake
4.  History of frequent urinary tract infections
5.  A focal impaction
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3ACT. It does not appear that other alternatives have been considered. Why might this be so?
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3TYK. Which action represents the appropriate nursing management of a client wearing a condom catheter?
1.  Ensure that the tip of the penis fits snugly against the end of the condom.
2.  Check the penis for adequate circulation 30 minutes after applying.
3.  Change the condom every 8 hours.
4.  Tape the collecting tubing to the lower abdomen.
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4ACT. Incontinence can lead to client decisions to limit social interactions. What would be an appropriate response if Mr. Baker states that he will just stay home until he has his surgery?
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4TYK. The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action?
1.  Leaves the catheter in place and gets a new sterile catheter.
2.  Leaves the catheter in place and asks another nurse to attempt the procedure.
3.  Removes the catheter and redirects it to the urinary meatus.
4.  Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.
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5TYK. Which statement indicates a need for further teaching of the home care client with a long-term indwelling catheter?
1.  “I will keep the collecting bag below the level of the bladder at all times.”
2.  “Intake of cranberry juice may help decrease the risk of infection.”
3.  “Soaking in a warm tub bath may ease the irritation associated with the catheter.”
4.  “I should use clean technique when emptying the collecting bag.”
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6TYK. During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate?
1.  Stress Urinary Incontinence
2.  Reflex Urinary Incontinence
3.  Functional Urinary Incontinence
4.  Urge Urinary Incontinence
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7TYK. A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to the client? Select all that apply.
1.  Limit fluids to avoid the burning sensation on urination.
2.  Review symptoms of UTI with the client.
3.  Wipe the perineal area from back to front.
4.  Wear cotton underclothes.
5.  Take baths rather than showers.
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8TYK. The nurse will need to assess the client’s performance of clean intermittent self-catheterization (CISC) for a client with which” urinary diversion?
1.  Ileal conduit
2.  Kock pouch
3.  Neobladder
4.  Vesicostomy
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9TYK. Which focus is the nurse most likely to teach for a client with a flaccid bladder?
1.  Habit training: Attempt voiding at specific time periods
2.  Bladder training: Delay voiding according to a prescheduled timetable.
3.  Crede’s maneuver: Apply gentle manual pressure to the lower abdomen.
4.  Kegel exercises: Contract the pelvic muscles.
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