Nursing Elites

1. A client with overflow incontinence needs assistance with elimination. What intervention should the nurse include in the plan of care?

• A. Stroke the medial aspect of the thigh.
• B. Use intermittent catheterization.
• C. Provide digital anal stimulation.
• D. Use the Valsalva maneuver.

Correct answer: D

Rationale: In clients with overflow incontinence, the voiding reflex arc is impaired. The Valsalva maneuver, which involves holding the breath and bearing down as if to defecate, can help initiate voiding by applying mechanical pressure. Options A and C (stroking the thigh or anal stimulation) rely on an intact reflex arc to trigger elimination and are not effective for clients with overflow incontinence. Intermittent catheterization (Option B) is a last resort due to the high risk of infection and should only be considered if other interventions fail.

2. A healthcare professional is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which of the following coexisting problems is cause for the healthcare professional to suspect that the oxygen saturation readings are not entirely accurate?

• A. Infection
• B. Hypertension
• C. Low blood pressure
• D. Loss of cough reflex

Correct answer: C

Rationale: Low blood pressure (hypotension), shock, and the use of peripheral vasoconstricting medications can lead to inaccurate pulse oximetry readings due to impaired peripheral perfusion. Hypertension and infection are not typically associated with inaccurate pulse oximetry readings, while the loss of cough reflex does not directly affect oxygen saturation readings.

3. The client with chronic renal failure is being taught about dietary restrictions by the nurse. Which of the following food items should the client avoid?

• A. Apples
• B. Bananas
• C. Chicken
• D. Rice

Correct answer: B

Rationale: The correct answer is B: Bananas. Bananas are high in potassium, which should be limited in clients with chronic renal failure to prevent hyperkalemia. Apples (choice A), chicken (choice C), and rice (choice D) are not typically restricted in clients with chronic renal failure. Apples and rice are lower in potassium, while chicken is a good source of lean protein, which is usually encouraged in these clients to meet their protein needs without excess potassium intake.

4. A client with diabetes begins to cry and says, 'I just cannot stand the thought of having to give myself a shot every day.' Which of the following would be the best response by the nurse?

• A. If you do not give yourself your insulin shots, you will die.
• B. We can teach your daughter to give the shots so you will not have to do it.
• C. I can arrange to have a home care nurse give you the shots every day.
• D. What is it about giving yourself the insulin shots that bothers you?

Correct answer: D

Rationale: The correct response is option D because it is an open-ended question that allows the client to express their feelings and concerns. This approach facilitates a therapeutic communication process by encouraging the client to verbalize their thoughts, emotions, and fears related to giving themselves insulin shots. Option A is incorrect as it uses a fear-inducing statement that may not be helpful in addressing the client's emotional needs. Option B assumes involvement of a family member without exploring the client's feelings further. Option C offers a solution without addressing the client's underlying concerns and emotions, potentially overlooking essential aspects of client-centered care.

5. A nurse cares for adult clients who experience urge incontinence. For which client should the nurse plan a habit training program?

• A. A 78-year-old female who is confused
• B. A 65-year-old male with diabetes mellitus
• C. A 52-year-old female with kidney failure
• D. A 47-year-old male with arthritis

Correct answer: A

Rationale: For a bladder training program to succeed in a client with urge incontinence, the client must be alert, aware, and able to resist the urge to urinate. Habit training will work best for a confused client. This includes going to the bathroom (or being assisted to the bathroom) at set times. The other clients may benefit from other types of bladder training. A confused client may need structured assistance to establish a regular bathroom routine, which can help manage urge incontinence effectively. Clients with diabetes mellitus, kidney failure, or arthritis may require different strategies tailored to their specific conditions.

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