Which client should the nurse assess frequently because of the risk for overflow incontinence?- Skildor

Question 1 of 5

Which client should the nurse assess frequently because of the risk for overflow incontinence?

A. A client who is bedfast, with increased serum BUN and creatinine levels B. A client with hematuria and decreasing hemoglobin and hematocrit levels C. A client who has a history of frequent urinary tract infections D. A client who is confused and frequently forgets to go to the bathroom

Correct Answer: A

Rationale: The correct answer is A. Bedfast clients with increased serum BUN and creatinine levels are at high risk for overflow incontinence. This occurs due to decreased bladder function and reduced ability to sense bladder fullness, leading to the bladder overfilling and leaking urine. Choice B describes symptoms related to possible urinary tract infections or renal issues, but these do not directly indicate overflow incontinence. Choice C, a history of frequent urinary tract infections, may suggest other urinary issues but not specifically overflow incontinence. Choice D, a confused client who forgets to go to the bathroom, is more indicative of functional incontinence rather than overflow incontinence.

Question 2 of 5

The nurse is assigned to care for a client diagnosed with psoriasis. What behavior by the nurse addresses this client's psychosocial need for acceptance?

A. Wearing gloves when providing care to the client B. Encouraging the client to join a support group C. Shaking hands with the client during an introduction D. Allowing the client to express their feelings openly

Correct Answer: B

Rationale: Encouraging the client to join a support group is the best option to address the client's psychosocial need for acceptance. Support groups provide a sense of belonging, understanding, and acceptance from peers who share similar experiences. This helps the client feel accepted despite their condition. Wearing gloves when providing care, shaking hands during an introduction, and allowing the client to express feelings openly are important but do not directly address the client's need for acceptance.

Question 3 of 5

A client is admitted to the hospital with a serum sodium level of 128 mEq/L, distended neck veins, and lung crackles. What intervention should the nurse implement?

A. Increase the intake of salty foods B. Administer NaCl supplements C. Restrict oral fluid intake D. Hold the client's loop diuretic

Correct Answer: C

Rationale: In the scenario described, the client presents with signs of fluid overload and hyponatremia. Restricting oral fluid intake is the appropriate intervention to manage fluid overload and correct hyponatremia. Increasing the intake of salty foods (Choice A) and administering NaCl supplements (Choice B) would exacerbate the sodium imbalance. Holding the client's loop diuretic (Choice D) is not directly related to addressing the fluid overload and hyponatremia.

Question 4 of 5

A 37-year-old client diagnosed with chronic kidney disease (CKD) is being treated for renal osteodystrophy. Which nursing diagnosis is most likely to be included in this client's plan of care?

A. High risk for infection related to subclavian catheter B. High risk of injury related to ambulation C. Knowledge deficit related to a high-protein diet D. Hygiene self-care deficit related to uremic frost

Correct Answer: D

Rationale: The correct answer is D. Uremic frost is a condition in which urea and other waste products are excreted through the skin, leaving a powdery residue. This indicates poor hygiene and self-care, common issues in patients with CKD and renal osteodystrophy. Proper hygiene measures are essential to prevent complications. Choices A, B, and C are less likely to be included in the plan of care for a CKD patient with renal osteodystrophy. Choice A is more related to a vascular access issue, choice B is more related to mobility concerns, and choice C is more related to dietary education.

Question 5 of 5

A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?

A. Call the radiology department B. Reinsert the implant into the vagina C. Apply double gloves to retrieve the implant for disposal D. Place the implant in a lead container using long-handled forceps

Correct Answer: D

Rationale: The correct action for the nurse to take when finding a radiation implant in the bed is to place the implant in a lead container using long-handled forceps. This action is crucial to minimize radiation exposure to both the patient and healthcare providers and ensure the safe disposal of the radioactive material. Calling the radiology department (choice A) may lead to unnecessary delays in addressing the immediate safety concern. Reinserting the implant into the vagina (choice B) is contraindicated and can cause harm. Applying double gloves to retrieve the implant for disposal (choice C) is not adequate for ensuring proper containment and handling of the radioactive implant, which requires specialized equipment like a lead container and long-handled forceps.

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