Theory #4 - Elimination, Sleep & Pain, Fluid & Electrolyte Imbalance (Textbook Questions)

The intake and output record of a client with a nasogastric tube that has been attached to suction for two days shows greater output and input. Which nursing diagnoses are most applicable? Select all that apply. 1. Deficient fluid volume. 2.Risk for deficient fluid volume. 3.Impaired oral mucous membranes. 4.Impaired gas exchange. 5.Decreased cardiac output

1, 3, 5. RATIONALE: The data indicates an actual problem, which excludes option 2. Option 4 related more to fluid volume excess.

A female client has a UTI. Which teaching points by the nurse would be helpful to the client? Select all that apply. 1. Limit fluids to avoid the burning sensation on urination 2. Review symptoms of UTI with the client 3. Wipe the perineal are from back to front 4. Wear cotton underclothes 5. Take baths rather than showers

2 and 4. RATIONALE: Option 2 validates the diagnosis. Cotton underwear promotes appropriate exposure to air, resulting in decreased bacterial growth (option 4). Incerased fluids decrease concentration and irritation (option 1). The client should wipe from front to back to prevent spread of bacteria (option 3). Showers reduce exposure of are to bacteria (option 5)

During assessment of the client with urinary incontinence, the nurse is most likely to asses for which fo the following? Select all that apply. 1. Perineal skin irritation 2. Fluid intake of less than 1,500 mL/day 3. History of antihistamine intake 4. History of frequent UTI 5. A fecal impaction

1, 2, 4, and 5. RATIONALE: The perineum may become irritated by the frequent contact with urine (option 1). Normal fluid intake is at least 1500 mL/day anc clients often decrease their intake to try to minimize urine leakage (option 2). UTIs can contribute to incontinence (option 4). A fecal impaction can compress the urethra, which can result in small amounts of urine leakage (option 5). Antihistamines can cause urinary retention rather than incontinence (option 3).

Which nursing diagnoes is/are most applicable to a client with fecal incontinence? Select all that apply. 1. Bowel incontinence 2. Risk for deficient fluid volume 3. Disturbed social image 4. Social isolation 5. Risk for impated skin integrity

1, 3, 4, and 5. RATIONALE: Option 1 is the most appropriate. The client is unable to decide when stool evacuation will occur. In option 3, client thoughts about self may be altered if unable to control stool evacuation. In option 4, client may not feel as comfortable around others. In option 5, increases tissue contact with deval material may result in impairment. Option 2 is more appropriate for a client with diarrhea. Incontinence is the inability to control feces of normal consistency.

During admission to a hospital unit, the client tells the nurse that her sleep tends to be very light and that it is difficult for her to get back to sleep if she's awakened at night. Which interventions should the nurse implement? Select all that apply. 1. Remind colleagues to keep their conversation to a minimum at night. 2. Encourage the client's faily members to bring in a radio to play soft music at night. 3. Deliver necessary medications and procedures at 1.5 or 3 hour intervals between 11pm and 6 am. 4. Encourage the client to ask family members to bring in a fan to provide white noise. 5. Incrase the temperature in the room.

1, 3, and 4. RATIONALE: Music is not usually recommended because it can be interesting to listen to. And a room that is too warm is not usually conducive for sleep.

A college student was referred to the campus health service because of difficulty staying awake in class. What should be included in the nurse's assessment? Select all that apply. 1. Amount of sleep he usually obtains during the week and on weekends 2. How much alcohol he usually consumes 3. Onset and duration of symptoms 4. Whether or not his classes are boring 5. What medications, including herbal remedies, he is taking

1, 3, and 5. RATIONALE: Although alcohol abuse or binge drinking can cause health problems, neither is likely to cause excessive daytime sleepiness (option 2). Unless the person is sleep deprived, boring classes will not induce sleep (option 4).

The client recovering from abdominal surgery refuses analgesia, saying that he is "fine, as long as he doesn't move." Which nursing diagnosis should be a priority? 1. Deficient Knowledge (pain control measures) 2. Ineffective Health Maintenance 3. Risk for Ineffective Airway Clearance 4. Impaired Physical Mobility

1. RATIONALE: Based on the information provided, the nurse needs to determine the client's understanding of the effects of pain on recovery and if the client has misconceptions about pain. Option 2 usually pertaiins more to chronic pain and fatigue. Options 3 and 4 could be true, but the priority is Option 1.

Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following? 1. Constipation 2. Diarrhea 3. Incontinence 4. Hemorrhoids

1. RATIONALE: Diarrhea will not result -- if anything there is increased opportunity for water reabsorption because the stool remains in the colon, leading to a firmer stool. Ignoring the urge shows a strong voluntary sphincter, not a weak one that could result in incontinence. Hemorrhoids would occur only if severe drying out of the stool occurs and, thus, repeated need to strain to pass stool.

During a well-child visit, a mother tells the nurse that her 4-year-old daughter typically goes to bed at 10:30 pm and awakens each morning at 7 am. She does not take a nap in the afternoon. Which is the best response by the nurse? 1. Encourage the mother to consider putting her daughter to bed between 8 and 9 pm. 2. Reassure the mother that it is normal for 4-year-olds to resist napping, but encourage her to insist that she rest quietly each afternoon. 3. Recommend that her daughter be allowed to sleep later in the morning. 4. Reassure her that her daughter's sleep pattern is normal and that she has outgrown her need for an afternoon nap.

1. RATIONALE: Preschool children require 10-12 hours of sleep per night.

A new nursing graduate's first job requires 12-hour night shifts. Which strategy will make it easier for the graduate to sleep during the day and remain awake at night? 1. Wear dark wrap-around sunglasses when driving home in the morning, and sleep in a darkened bedroom. 2. Exercise on the way home to avoid having to stand around waiting for equipment at the gym. 3. Drink several cups of strong coffee or 16 oz of caffeinated soda when beginning the shift. 4. Try to stay in a brightly lit area when working at night

1. RATIONALE: Reducing exposuer to bright light in the morning, when driving home, and when going to sleep will make it easier to fall asleep after work. Although working in a brightly lit area will reduce drowsiness, this strategy is rarely available to nurses working the night shift; lights are often dimmed in hospital corridors and client rooms (option 4).

The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action? 1. Leaves the catheter in place and gets a new sterile catheter. 2. Leaves the catheter in place and asks another nurse to attempt the procedure. 3. Removes the catheter and redirects it to the urinary meatus. 4. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.

1. RATIONALE: The catheter in the vagina is contaminated and cannot be reused. If left in place, it may help avoid mistaking the vaginal opening for urinary meatus. A single failure to catheterize the meatus does not indicate that another nurse is needed although sometimes s second nurse can assis in visualizing the meatus (option 2).

A client who had abdominal surgery 4 hours ago is receiving a continuous epidural infusion of an analgesic. Which of the following observations indicates the nurse should monitor the client closely? 1. Drowsy; drifts off to sleep before completing a sentence 2. Respirations = 18/min 3. Drowsy; easily aroused 4. Pain rating 1-2/10

1. RATIONALE: increasing level of sedation = early sign of impending respiratory depression. Option 2 is normal. Option 3 can indicate increasing sedation; hpwever, option 1 describes a higher level of sedation and an intervention such as notifying the primary care provider. Option 4 indicates pain management that may be tolerable for the client.

Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes? Select all that apply. 1. Voids each time there is an urge. 2. Practices slow, deep breathing until the urge decreases 3. Uses adult diapers, for "just in case." 4. Drinks citrus juices and carbonated beverages 5. Performs pelvic muscle exercises

2 and 5. RATIONALE: It is important for the client to inhibit the urge-to-void sensation when a premature urge is experienced. Some clients may need diapers; this is not the BEST indicator of a successful program (option 3). Citrus juices may irritate the bladder (option 4). Carbonated beverages increase diuresis and the risk of incontinence (option 4).

The client is supposed to have a fecal occult blood test done on a stool sample. The nurse is going to use the Hemoccult test. Which of the following indicates that the nurse is using the correct procedure? Select all that apply. 1. Mixes the reagent with the stool sample before applying to the card. 2. Collects a sample from two different areas of the stool specimen. 3. Assesses for a blue color change. 4. Asks a colleague to verify the pink color results. 5. Asks the client if he has taken vitamin C in the past few days.

2, 3, and 5. RATIONALE: The Option 1 is incorrect since the reagent is placed on the specimen after it is applied to the testing card. Option 4 is incorrect because a pink color owuld be considered nefative and does not require verification.

The nurse would assess for signs of hypomagnesemia in which of the following clients? Select all that apply. 1. A client with renal failure 2. A client with pancreatitis 3. A client taking magnesium-containing antacids 4. A client with excessive nasogastric drainage 5. A client with chronic alcoholism

2, 4, 5. RATIONALE: Options 1 and 3 relate to hypermagnesemia.

The nurse needs to collect a sputum specimen to identify the presence of tuberculosis (TB). Which nursing action(s) is/are indicated for this type of specimen? Select all that apply. 1. Collect the specimen in the evening. 2. Send the specimen immediately to the laboratory. 3. Ask the client to spit into the sputum container. 4. Offer mouth care before and after collection of the sputum specimen. 5. Collect a specimen for 3 consecutive days.

2, 4, and 5. RATIONALE: Option 1 is incorrect because the sputum specimen is colelcted in the morning. Option 3 is incorrect because "spit" incdicates that saliva is being examined. The clien needs to cough up or expectorate mucus or sputum.

Which interventions, when implemented by the nurse, would apply the gate control theory of pain? Select all that apply. 1. Oral analgesics around the clock 2. Massage 3. Patient-controlled analgesia 4. Heat or cold application 5. Acupressure

2, 4, and 5. RATIONALE: Options 1 and 3 are pharmacologic interventions, which are important; however, they inhibit the pain during the transmission phase of nociception.

A client is admitted for a sleep disorder. The nurse knows that the reticular activating system (RAS) is involved in the sleep/wake cycle. In the accompanying illustration, which letter indicates the location of the RAS? 1. Cerebellum 2. Brainstem 3. Pituitary Gland 4. Cerebrum

2.

Which action represents the appropriate nursing managements of a client wearing a condom catheter? 1. Ensure that the tip of the penis fits nugly against the end of the condom 2. Check the penis for adequates circulatione every 30 minutes after applying 3. Change the condom every 8 hours 4. Tape the collecting tubing to lower the abdomen

2. RATIONALE: A 1 in. space should be left between the penis and the end of the condom (option 1). The condom is changed every 24 hours (option 3), and the tubing is taped to the leg or attached to a leg bad (option 4). An indwelling catheter is secured to the lower abdomen or upper thigh.

An older nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect which assessment finding? 1. Increased blood pressure 2. Weak, rapid pulse 3. Moist mucous membranes 4. Jugular vein distention

2. RATIONALE: A client who has not eaten or drunk anything anything for several days would be experiencing fluid volume deficit.

Because of significant concerns about financial problems a middle-aged client complains of difficulty sleeping. Which outcome would be the most appropriate for the nursing care plan? By day 5, the client will: 1. Sleep 8-10 hours per day." 2. Report falling asleep within 20 to 30 minutes." 3. Have a plan to pay all bills." 4. Decrease worrying about financial problems and will keep busy until bedtime."

2. RATIONALE: Falling asleep within 20-30 minutes is normal for adults.

A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past 2 days. She appears lethargic and is complaining of leg cramps. What should the nurse do first? 1. Start an IV. 2. Review the results of serum electrolytes. 3. Offer the woman foods that are high in sodium and potassium content. 3. Administer an antiemetic.

2. RATIONALE: Further assessment is needed to determine appropriate action. While the nurse may perform some of the intervention in 1,3, and 4, assessment is needed initially.

A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past 2 days. She appears lethargic and is complaining of leg cramps. What should the nurse do first? 1. Start an IV. 2. Review the results of serum electrolytes. 3. Offer the woman foods that are high in sodium and potassium content. 3. Administer an antiemetic.

2. RATIONALE: Further assessment is needed to determine appropriate action. While the nurse may perform some of the interventions in 1,3, and 4, assessment is needed initially.

When a client has arrived at the nursing unit from surgery, the nurse is most likely to give priority to which of the following assessments? 1. Pain tolerance 2. Pain intensity 3. Location of pain 4. Pain history

2. RATIONALE: In a postoperative client it is important to assess pain intensity frequently to manage the acute pain experience. Option 1: the most pain a person is willing to tolerate before tkaing action can be discussed with the client after the pain intensity has been assessed. Option 4: important but not for a client in acute pain.

Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection? 1. The client will wear a medical alert bracelet for antibiotic allergy. 2. The client will return to his or her previous fecal elimination pattern. 3. The client will verbalize the need to take an antidiarrheal medication prn. 4. The client will increase intake of insoluble fiber such as grains, rice, and cereals.

2. RATIONALE: Once the cause of diarrhea has been identified and corrected, the client should return to his or her previous elimination pattern. This is not an example of an allergy to the antibiotic but a common consequence of overgrowth of bowel organisms not killed by the drug. Antidiarrheal medications are usually prescribed according to the number of stools, not routinely around the clock. Increasing intake of soluble fiber such as oatmal or potatoes may help absorb excess liquid and decrease the diarrhea, but insoluble fiber will not.

An older man is admitted to the medical unit with a diagnosis of dehydration. Which sign or symptom is most representative of a sodium imbalance? 1. Hyperreflexia 2. Mental confusion 3. Irregular pulse 4. Muscle weakness

2. RATIONALE: Sodium contributes to the function of neural tissue. Calcium contributes to the function of voluntary muscle contraction.

A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action? 1. Prepare to irrigate the colostomy. 2. After assessing the stoma and surrounding skin, notify the surgeon. 3. Assess bowel sounds and administer antiemetic. 4. Administer a bulk-forming lacative, and encourage increased fluids and exercise.

2. RATIONALE: The client has assessment findings consistent with complications of surgery. Irrigating the stoma is a dependent nursing action, and is also intervention withouth appropriate assessment. Assessing the peristomal skin area is an independent action, but administering an antiemetic is an intervention without appropriate assessment. Antiemetics are generally ordered to treat immediate postoperative nausea, not several days postoperative. Administering a bul-dorming laxatice to a nauseated postoperative client is contraindicated.

Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? 1. "I need to drink one and a half to two quarts of liquid each day." 2. "I need to take a laxative such as Milk of Magnesia if I don't have a BM every day." 3. "If my bowel pattern changes on its own, I should call you." 4. "Eating my meals at regular times is likely to result in regular bowel movements."

2. RATIONALE: The standard of practice in assisting older adults to maintain normal function of the GI tract is regular ingestion of a well-balanced diet, adequate fluid intake, and regular exercise. If bowel pattern is not regular with these activities, this abnormality should be reported. Stimulant laxatives can be very irritating and are not the preferred treatment for occasional constipation in older adults.

Which statement best reflects the nurse's assessment of the fifth vital sign? 1. "Do you have any complaints?" 2. "Are you experienceing any discomfort right now?" 3. "Is there anything I can do for you now?" 4. "Do you have any complaints of pain?"

2. RATIONALE: The word pain or complain may have emotional or sociocultural meanings.

The nurse will need to assess the client's performance of clean intermittent self-catheterization (CISC) for a client with which urinary diversion? 1. Ileal conduit 2. Kock pouch 3. Neobladder 4. Vesicostomy

2. RATIONALE:The ieleal conduit and vesicostomy (options 1 and 4) are incontinent urinary diversions, and clients are requires to use an external ostomy appliance to contain the urine. Clients with a neobladder can control their voiding (option 3).

When planning care for pain control of older clients, which principles should the nurse apply? Select all that apply. 1. Pain is a natural outcome of the aging process. 2. Pain perception increases with age. 3. The client may deny pain 4. The nurse should avoid use of opioids 5. The client may describe pain as an "ache" or "discomfort"

3 and 5.

Which statement indicates a need for further teaching of the home care client with a long-term indwelling catheter? 1. "I will keep the collecting bad below the level of the bladder at all times." 2. "Intake of cranberry juice may help decrease the risk of infection." 3. "Soaking in a warm tub bath may ease the irritation associated with the catheter." 4. "I should use clean technique when emptying the collecting bag."

3. RATIONA:E: Soaking in a bathtub can increase the risk of exposure to bacteria.

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy? 1. The stoma extends 1/2 in. above the abdomen. 2. The skin under the appliance looks red briefly after removing the appliance. 3. The stoma color is a deep red-purple. 4. An ascending colostomy delivers liquid feces.

3. RATIONALE: An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. The skin under the appliance may remain pink/red for a while after the adhesive is pulled off. Feces from an ascending ostomy are very liquid, less so from a transverse ostomy, and more solid from a descending or sigmoid stoma.

Which focus is the nurse most likely to teach for a client with a flaccid bladder? 1. Habit training: attempt voiding at specific time periods. 2. Bladder training: delay voiding according to a preschedule timetable. 3. Credé's maneuver: apply gentle manual pressure to the lower abdomen. 4. Kegel exercises: contract the pelvic muscles.

3. RATIONALE: Because bladder muscles will not contract to increase the intrabladder pressure to promote urination, the process is intiated manually.

Which of the following is most likely to validate that a client is experiencing intestinal bleeding? 1. Large quantities of fat mized with pale yellow liquid stool 2. Brow, formed stools 3. Semisoft black-colored stools 4. Narrow, pencil-shaped stool

3. RATIONALE: Blood in the upper GI tract is black and tarry. Option 1 can be a sign of malabsorption in an infant. Option 2 is normal stool. Option 4 is characteristic of an obstructive condition of the rectum.

The nurse is answering questions after a presentation on sleep at a local senior citizens center. A woman in her late 70s asks for an opinion about the advisability of allowing her husband to nap for 15-20 minutes each afternoon. Which is the nurse's best response? 1. "Taking a nap an afternoon nap will interfere with his being able to sleep at night. If he's tired in the afternoon, see if you can interest him in some type of stimulating activity to keep him awake." 2. "He shouldn't need to take an afternoon nap if he's getting enough sleep at night." 3. "Unless your husband has trouble falling asleep at night, a brief afternoon nap is fine." 4. "Encourage him to consume coffee or some other caffeinated beverage at lunch to prevent drowsiness in the afternoon."

3. RATIONALE: Napping frequently reappears in older adults.

The nurse assess a client's abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling "bloated." The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema? 1. Soapsuds 2. Retention 3. Return flow 4. Oil retention

3. RATIONALE: THis provides relief of postoperative flatus, stimulating bowel motility. Options 1, 2, and 4 manage vconstipation and do not provide flatus relief.

A 78-year-old male client needs to complete a 24-hour urine specimen. In planning his care, the nurse realizes that which measure is most important? 1. Instruct the client to empty his bladder and save this voiding to start the collection. 2. Instruct the client to use sterile individual containers to collect the urine. 3. Post a sign stating "Save All Urine" in the bathroom. 3. Keep the urine specimen in the refrigerator.

3. RATIONALE: This will inform the staff that the client is on a 24-hour urine collection. Option 1 is not appropriate since the firwst voided specimen is to be discarded. Option 2 is not an appropriate nursing measure since the specimen container is clean not sterils, and one container is needed - not individual containers. Options 4 is inappropriate because some 24-hours urin collections do not require refrigeration.

During the transduction phase of nociception, which method of pain control ismost effective? 1. Tricylic antidepressants 2. Opioids 3. Ibuprofen 4. Distraction

3. RATIONAlE: During the transduction phase, tissue injury triggers the release of biochemical mediators such as prostagladin. The coanalgesic medication in option 1 would affect the modulation phase because coanalgesics inhibit reuptake of norepinephrine and serotonin, which increases the modulation phase that helps inihibit painful ascending stimuli. Opioids block the release of neurotransmitters, particularly substance P, which stops tha pain at the spinal evel that occurs during the transmission phase. Distraction is best used during the perception phase away from the pain.

A client who describes his pain as 7 on a scale of 0 to 10 is classified as having which of the following: 1. No pain 2. Mild pain 3. Moderate pain 4. Severe pain

4.

The client has an order of morphine 2.5 to 5.0 mg IV every 4 hours. He received 2.5 mg IV 4 hours ago for pain rated at 3 on a scale of 0 to 10. He is now watching television and visiting with family members. When asked about his pain, he rates it as a 5. His vital signs are stable. What nursing interventions is the most appropriate? 1. Give morphine 3.5 mg IV and inform him to continue watching TV because it is a distraction from the pain. 2. Give 2.5 mg of morphine IV to avoid the client becoming addicted. 3. Give nothing at this time because he is not echibiting any sings of pain. 4. Give morphine 5.0 mg IV and reasses in 20 minutes.

4. RATIONALE: His pain rating warrant higher dose of the PRN morphine. With option 1, you would be undermedicating the client based on his perception or rating of the pain. Option 2: research shows that few clients become addicted, plus there are no signs of addiction. Option 3 does not adress the intensity as well as option 4.

A client has a history of sleep apnea. Which is the most appropriate question for the nurse to ask? 1. Do you have a history of cardiac irregularities? 2. Do you have a history of any kind of nasal obstruction? 3. Have you ehad chest pain with or without activity? 4. Do you have difficulty with daytime sleepiness?

4. RATIONALE: If they don't volunteer this, clients should be asked if they fall asleep or struggle to stay awake at work. Althoug cardiac arrhythmias may occur, they are usually only detectable during a sleep study, and thus the client would not be aware of them (option 1). Nasal obstruction is rarely the cause of sleep apnea or a complaint of clients with sleep apnea (option 2). There are many causes of chest pain, and this is unlikely to be something reported by clients with sleep apnea unless they have underlying cardiac disease (option 3).

The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? 1. The bladdes distends and its capacity increases 2. Older adults ignore the need to void 3. Urine becomes more concentrated 4. The amount of urine retained after voiding increases

4. RATIONALE: Older adults do not ignore the urge to void and may have difficulty in getting to the toilet in time (option 2). The kidney becomes less able to concentrate urne with age (option 3)

During an admission nursing assessment, a client with diabetes describes his lef pain as a "dull, burning sensation." The nurse recognizes his description to be characteristic of which type of pain? 1. Physiological 2. Somatic 3. Visceral 4. Neuropathic

4. RATIONALE: Options 2 and 3 are subcategories of option 1.

Which client statement indicates a need for further teaching regarding treatment for hypokalemia? 1. "I will use avocado in my salads." 2."I will be sure to check my heart rate before I take my digoxin." 3. "I will take my potassium in the morning after eating breakfast." 4. "I will stop using my salt substitute."

4. RATIONALE: Salt substitues contain potassium. The client can still use it within reason. Option 1: Avocado is higher in potassium than most foods. Option 2: hypokalemia can ptentiate digozin toxicity and checking the pulse will help the client avoid this. Option 3: it is important to take potssium with food to avoid gastric upset.

A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema? 1. Oil retention 2. Return flow 3. High, large volume 4. Low, small volume

4. RATIONALE: Small-volume enemas along with other preparations are used to prepare the client for this procedure. An oil retention enema is used to soften hard stool. Terun flow enemas help expel flatus. Because of the risk of loss of fluid and electrolytes, high, large-volume enemas are seldom used.

A client reports to the nurse that she has been taking barbiturate sleeping pills every night for several months and now wishes to stop taking them. Which statement is the most appropriate advice for the nurse to provide the client? 1. Take the last pill on a Friday night so disrupted sleep can be compensated on the weekend. 2. Continue to take the pills since sleeping without them after such a long time will be difficult and perhaps impossible. 3. Discontinue taking the pills. 4. Continue taking the pills and discuss tapering the dose with the primary care provider.

4. RATIONALE: Suddenyl stopping barbiturate sleeping pills can precipitate a danerous withdrawal.

During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate? 1. Stress Urinary Incontinence 2. Reflex Urinary Incontinence 3. Functional Urinary Incontinence 4. Urge Urinary Incontinence

4. RATIONALE: THe key phrase is the "urge to void."

During a yearly physical, a 52-year-old male client mentions that his wife frequently complains about his snoring. During the physical exam, the nurse notes that his neck size is 18 inches, his soft palate and uvula are reddened and swollen, and he is overweight. What is the most appropriate nursing intervention for the nurse to recomment to this client. 1. Recommend that he and his wife sleep in separate bedrooms so that his snoring does not disturb his wide. 2. Refer him to a dietitian for a weight loss program. 3. Caution him not to drink or take sleeping pills since they may make his snoring worse. 4. Refer him to a sleep disorders center for evaluation and treatment of his symptoms.

4. RATIONALE: The client's symptoms and weight suggest that he has obstructive sleep apnea and hsould be referred to a sleep disorders specialist for further evaluation.

A client is admitted to the hospital for hypocalcemia. Nursing interventions relating to which system would have the highest priority? 1. Renal 2. Cardiac 3. Gastrointestinal 4. neuromuscular

4. RATIONALE: The major clinical signs and symptoms of hypocalcemia are due to increased neuromuscular activity and not the renal, cardiac, or GI systems.

A student nurse is assigned to care for a client with a sigmoidostomy. The student will assess which ostomy site?

5. RATIONALE: Option 1 is an ileostomy site. Option 2 is ascending colostomy Option 3 is transverse colostomy. Option 4 is descending colostomy.