What intervention should a nurse recommend for a client with stress incontinence?

Correct Answer: B

Rationale: The correct answer is B: Purchase absorbent undergarments. For stress incontinence, which is caused by weakened pelvic floor muscles, absorbent undergarments can help manage symptoms. Kegel exercises (choice A) strengthen pelvic floor muscles but may not provide immediate relief. Constipation (choice C) can exacerbate incontinence but is not the primary intervention. Surgical treatments (choice D) are not typically recommended as a first-line intervention for stress incontinence.

Correct Answer: A

Rationale: The correct answer is A: Open the airway. This is the first intervention because ensuring a clear airway is crucial for adequate oxygenation. If the airway is obstructed, oxygen administered or suctioning performed may not be effective. Checking for breathing should follow airway opening. Administering oxygen can be done once the airway is established. Suctioning is not the priority unless there is evidence of airway obstruction.

Correct Answer: D

Rationale: The correct answer is D (Morton's neuroma) because interventions for difficulty walking due to a foot mass include recommending proper footwear, orthotic devices, corticosteroid injections, physical therapy, and in severe cases, surgical removal of the mass. Morton's neuroma causes pain and tingling in the ball of the foot, leading to difficulty walking. Plantar fasciitis (A), Hallux valgus (B), and Hammertoe (C) do not typically present with a mass in the foot causing difficulty walking.

Correct Answer: A

Rationale: The correct answer is A: Assess airway. In caring for a client with a traumatic head injury, the first priority is to ensure there is a clear airway to maintain oxygenation and ventilation, which is crucial for brain function. If the airway is compromised, it can lead to hypoxia and further brain damage. Providing pain relief (B) is important but not the immediate priority. Monitoring intracranial pressure (C) is essential but comes after ensuring a patent airway. Maintaining a quiet environment (D) can help reduce stimulation, but it is not as critical as assessing the airway for immediate intervention.

Correct Answer: B

Rationale: The correct answer is B: Tenderness, warmth, and swelling at the site. Post-operative wound infection often presents with localized tenderness, warmth, and swelling due to inflammation and immune response. Redness, heat, and purulent drainage (choice A) can also indicate infection but are not specific to wound infections. Excessive swelling and redness (choice C) may be present in inflammatory responses but do not specifically point to an infection. Fever, chills, and nausea (choice D) can be systemic signs of infection but are not specific to wound infections. Tenderness, warmth, and swelling are more indicative of a localized wound infection.