Answer to Question 1
Correct Answer: 2
Rationale 1: A client with incontinence would wear some kind of undergarment pad. Cotton undergarments alone would not provide protection for catching the urine.
Rationale 2: Incontinence involves a small leakage of urine when a client laughs.
Rationale 3: Incontinence does not occur if a client just carries on a conversation.
Rationale 4: If the client has been experiencing incontinence, the nurse might expect to see the skin inflamed and irritated because urine is very irritating to the skin.
Answer to Question 2
Correct Answer: 4
Rationale 1: An elevated specific gravity is seen in dehydration.
Rationale 2: The glucose would be elevated in diabetic ketoacidosis.
Rationale 3: Blood would be present in trauma.
Rationale 4: The pH, glucose, specific gravity, and protein are all within normal limits. Urine is usually clear to slightly cloudy, and WBC count can be from 0 to 4. Therefore, the gross cloudiness and WBC count of 1015 are not normal, indicating a urinary tract infection.
Assess the nailbeds' configuration
To check pupillary reflexes the nurse first holds the penlight
Although males tend to be larger than females, the two overlap significantly in size. The size of a
Intervention Model-Response to Client Misconduct
Survey and posture of client: Lateral view
Testing client’s ability to identify sharp sensations