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    Hesi RN Foundation Of Nursing Proctored Exam

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    Question: 1 of 54Hesi rn foundation of nursing proctored exam
    Patient data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
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    Actions to Take

    Provide skin care
    Collect urine for a urinalysis and culture
    Place an indwelling catheter
    Create a toilet training program
    Secure the call bell so it is within reach

    Potential Conditions

    Functional incontinence
    Overflow urinary incontinence
    Reflex urinary incontinence
    Urge incontinence

    Parameters to Monitor

    Blood pressure
    Mobility
    Pain
    Skin integrity
    Postvoid residual

    Click or drag items into the slots above. Items can only go into their matching column.

    Explanation
    Potential Condition: Functional incontinence: This occurs when a person is continent but unable to reach the toilet due to physical limitations, environmental barriers, or cognitive impairment. In this case, the client is physically weak and could not access the bathroom or call for help in time. Actions to Take: Secure the call bell so it is within reach: This empowers the client to request assistance promptly, helping to prevent further episodes of incontinence. Create a toilet training program: Scheduled toileting or prompted voiding assists in managing incontinence related to functional limitations. Parameters to Monitor: Episodes of incontinence: Tracking frequency helps assess if interventions are reducing the number of episodes. Skin integrity: Incontinence increases the risk for skin breakdown, especially in older adults with limited mobility. Incorrect Potential Conditions: Overflow urinary incontinence: Involves dribbling due to bladder overdistension, typically from obstruction or weak detrusor muscles—not consistent with this client’s symptoms. Reflex urinary incontinence: Related to neurological impairment; the client shows no signs of spinal cord injury or neurological disease. Urge incontinence: Involves sudden urgency with loss of urine before reaching a toilet; not reported by the client.
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