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: 3
Rationale 1: Emptying the bladder completely every time she voids would not be realistic in the beginning. This will take time.
Rationale 2: Improved continence takes 3 to 6 months, so 1 month is not a realistic goal.
Rationale 3: Performing four to five squeezes for 5 to 10 seconds is the goal to start with when teaching a client Kegel exercises, which are used for stress and urge incontinence.
Rationale 4: Clients are not instructed to stop the flow of urine when voiding because this could lead to retention.
A parish nurse checks the blood pressure of a church member
A nurse administers an intermittent bolus feeding.
Abnormal physical assessment findings
Nurse collaboration
Using small, circular strokes, exfoliate the client’s neck and back.
Physical Findings of Cardiac Tamponade