A nurse needs to assess a client who is undergoing urinary diversion. Which of the ff assessment is essential for the client?

Correct Answer: C

Rationale: The essential assessment for a client undergoing urinary diversion is the client's knowledge about the effects of the surgery on his nervous control. Urinary diversion is a surgical procedure that involves redirecting urine flow from the bladder to a new exit point in the body due to bladder cancer, birth defects, or other medical conditions. Understanding the effects of the surgery on nervous control is crucial as it can impact the client's ability to control urination and bowel movements post-surgery. Educating the client about these effects will help in managing expectations and in planning for any necessary adjustments to their lifestyle and daily routine. It is important for the nurse to assess the client's level of understanding and provide appropriate education and support regarding nervous control changes that may result from the procedure.

Correct Answer: C

Rationale: Infants with congenital heart disease who have been admitted with heart failure may have difficulty feeding due to increased work of breathing and poor energy reserves. Offering small, frequent feedings can help prevent fatigue and provide adequate nutrition to support the infant's growth and recovery. It also helps to prevent overloading the heart with a large volume of fluids at once. This approach allows the infant to receive enough calories while reducing the risk of aspiration and conserving energy for feeding and breathing. Positioning the infant flat on the back may worsen respiratory distress, encouraging nutritional fluids alone may not address the feeding challenges faced by the infant, and measuring the head circumference is important for growth monitoring but may not be the priority when managing heart failure in this case.

Correct Answer: A

Rationale: Painless hematuria, which is the presence of blood in the urine without any associated pain, is an early indicator of bladder cancer. This symptom is often one of the first signs of this type of cancer and should be promptly evaluated by a healthcare provider. It is crucial not to ignore the presence of blood in the urine, as it can indicate various underlying conditions, including bladder cancer. While other symptoms like Nocturia (waking up at night to urinate), Occasional polyuria (increased urination), and Dysuria (painful urination) can also occur with bladder cancer, painless hematuria is a significant red flag for the disease.

Correct Answer: C

Rationale: Nephrotic syndrome is characterized by the presence of edema due to loss of protein in the urine. One of the nursing goals in managing a child with minimal change nephrotic syndrome receiving high doses of prednisone is to monitor for the development or worsening of edema. Detecting evidence of edema is important as it can help in assessing the effectiveness of treatment, such as monitoring the response to prednisone therapy and adjusting the treatment plan accordingly. Monitoring for edema can also help in preventing complications associated with fluid overload, such as hypertension and respiratory distress. Therefore, detecting evidence of edema is an appropriate nursing goal in this scenario.

Correct Answer: A

Rationale: Temper tantrums are common at this age and often do not indicate pathology.