Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes? Select all that apply.
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Solution
Answer: 2, 5
It is important for the client to inhibit the urge to void sensation when a premature urge is experienced. Some clients may need diapers; this is not the best indicator of a successful program (opt3). Citrus juices may irritate the bladder (opt4). Carbonated beverages increase diuresis and the risk of incontinence (opt4).
Which focus is the nurse most likely to teach for a client with a flaccid bladder?
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Solution
Because the bladder muscles will not contract to increase the intra-bladder pressure to promote urination, the process is initiated manually. Options one, two, and four: to promote continence bladder contractions are required for habit training, bladder training, and increasing the tone of the pelvic muscles.
The nurse will need to assess the client’s performance of clean intermittent self catheterization (CISC) for a client with which urinary diversion?
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Solution
The ileal conduit and vesicostomy (opt1,4) are in continent urinary diversions, and clients are required to use an external ostomy appliance to contain the urine. Clients with a neobladder can control their voiding (opt3).
A female client has a urinary tract infection. Which teaching points by the nurse should be helpful to the client? Select all that apply.
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Solution
Answer: 2, 4
Option two validates the diagnosis. Cotton underwear promotes appropriate exposure to air, resulting in decreased bacterial growth (opt4). Increased fluids decrease concentration and irritation (opt1). The client should wipe the perineal area from front to back to prevent spread of bacteria from the rectal area to the urethra (opt3). Showers reduce exposure of area to bacteria (opt5).
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?
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Solution
The key phrase is “the urge to void” option one occurs when the client coughs, sneezes, or jars the body, resulting in accidental loss of urine. Option two occurs with involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Option three is involuntary loss of urine related to impaired function.
Which statement indicates a need for further teaching of a home care client with a long term indwelling catheter?
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Solution
Soaking in a bathtub can increase the risk of exposure to bacteria. The bag should be below the level of the bladder to promote proper drainage (opt1). Intake of cranberry juice creates an environment nonconducive to infection (opt2). Clean technique is appropriate for touching the exterior portions of the system (opt4).
The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action?
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Solution
The catheter in the vagina is contaminated and can’t be reused.If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus doesn’t indicate that another nurse is needed although sometimes a second nurse can assist in visualization of the meatus (opt2).
Which action represents the appropriate nursing management of a client wearing a condom catheter?
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Solution
The penis and condom should be checked 1/2 hour after application to ensure that it’s not too tight. A 1 in. space should be left btw the penis and the end of the condom (opt1). The condom is changed every 24h (opt3) and the tubing is taped to the leg or attached to a leg bag. An indwelling catheter is taped to the lower abdomen or upper thigh (opt4).
During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply.
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Solution
Answer: 1, 2, 4, and 5
The perineum may become irritated by the frequent contact with urine (Opt1). Normal fluid intake is at least 1,500 mL/d and clients often decrease their intake to try to minimize urine leakage (Opt2). UTIs can contribute to incontinence (Opt4). A fecal impaction can compress the urethra, which results in sm. amts of urine leakage (Opt5). Antihistamines can cause urinary retention rather than urinary incontinence (Opt3).
The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following?
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Solution
The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained (Option 4). Older adults don’t ignore the urge to void and may have difficulty getting to the toilet in time (Option 2). The kidney becomes less able to concentrate urine with age (Option3).