Author Question: The nurse has established an objective for a client who has been unable to void. The client's intake ... (Read 122 times)

Melani1276 · **on:** Jul 22, 2018

The nurse has established an objective for a client who has been unable to void. The client's intake will be at least 1000 mL between 7:00 A.M. and 3:30 P.M. Which one of the following in-dicates successful feedback from the client?

a. The client voids at least 1000 mL during the shift.
b. The client verbalizes abdominal comfort without pressure.
c. The client has adequate intake and output.
d. The client drinks 240 mL of fluid five or six times during the shift.

Question 2

A 74-year-old client has been having sleeping difficulties. To have a better idea of the client's problem, how should the nurse respond?

a. What do you do just prior to going to bed?
b. Let's make sure that your bedroom is completely darkened at night.
c. Why don't you try napping more during the daytime?
d. You should always eat something just before bedtime.

ju · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D
The nurse evaluates success by observing the client's performance of each expected behaviour. Feedback indicating success in this situation is the client drinking 240 mL of fluid five or six times during the shift. This would total a fluid intake of 1200 to 1440 mL, meeting the objective of at least 1000 mL during the designated period.
Voiding at least 1000 mL during the shift is not the objective. The objective is to have the client drink at least 1000 mL during the designated period.
Verbalizing abdominal comfort without pressure is not an evaluation of the objective regarding specific fluid intake.
Having adequate intake and output is not accurate feedback indicating success. The term ade-quate is not quantified.

Answer to Question 2

A
To assess the client's sleeping problem, the nurse should inquire about predisposing factors, such as by asking, What do you do just before going to bed? Assessment is aimed at understanding the characteristics of any sleep problem and the client's usual sleep habits so that ways for pro-moting sleep can be incorporated into nursing care.
Older adults may prefer to sleep in softly lit rooms.
Napping more during the daytime is often not the best solution. The nurse should first assess the client's sleeping problem.
The client does not always have to eat something before going to bed. The nurse should first as-sess the client's current sleep habits.