A nurse is providing instructions about a 24-hour urine collection to an adolescent client. Which of the following should the nurse include in the teaching?
Discard the first voided specimen.
Void every hour.
Save the final specimen in a separate container.
Cleanse the perineum with a povidone-iodine solution prior to voiding.
The Correct Answer is A
Choice A rationale
The first voided specimen is discarded to ensure that the 24-hour urine collection starts with an empty bladder and accurately reflects the urine produced over the entire period.
Choice B rationale
Voiding every hour is not necessary and may not be practical for a 24-hour urine collection.
Choice C rationale
The final specimen should be included in the same container as the rest of the 24-hour urine collection.
Choice D rationale
Cleansing the perineum with a povidone-iodine solution is not required for a 24-hour urine collection.
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Correct Answer is B
Explanation
Choice A rationale
Lengthening the harness straps weekly is not recommended. The Pavlik harness is designed to maintain the hip joint in a stable position to promote proper development. Adjusting the straps without professional guidance can compromise the effectiveness of the treatment and potentially harm the infant.
Choice B rationale
Positioning the diaper over the straps with each change is correct. This ensures that the harness remains in the correct position and prevents soiling of the harness, which can lead to skin irritation and infection.
Choice C rationale
Massaging the skin under the straps daily is not advised. The harness should remain in place to maintain the correct hip position. Removing the harness for skin massage can disrupt the treatment.
Choice D rationale
Applying lotion to the skin beneath the straps twice daily is not recommended. Lotions can cause the skin to become too moist, leading to skin breakdown and irritation. The harness should remain dry to prevent skin issues.
Correct Answer is B
Explanation
Choice A rationale
This statement is nontherapeutic because it shifts the focus away from the patient and onto the nurse’s personal experience. It can minimize the patient’s feelings and is not helpful in providing support.
Choice B rationale
Asking the patient to demonstrate how they give themselves insulin is a therapeutic communication technique. It shows interest in the patient’s self-care practices and provides an opportunity for the nurse to offer guidance and support.
Choice C rationale
This statement is nontherapeutic because it offers false reassurance. It does not address the patient’s concerns or provide any real support.
Choice D rationale
This statement is also nontherapeutic because it offers false reassurance and does not address the patient’s specific concerns or needs.