A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence?
Overflow incontinence
Reflex incontinence
Stress incontinence
Urge incontinence
The Correct Answer is A
Choice A rationale: Overflow incontinence is characterized by a constant leakage of small amounts of urine and a distended, palpable bladder due to incomplete emptying. This is consistent with the client's symptoms.
Choice B rationale: Reflex incontinence is associated with neurologic dysfunction but does not typically involve constant leakage.
Choice C rationale: Stress incontinence is associated with increased intra-abdominal pressure and typically involves leakage with activities like coughing or sneezing.
Choice D rationale: Urge incontinence is characterized by a sudden, strong urge to void and is not typically associated with constant leakage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: A deep tissue injury involves intact skin with a purple or maroon localized area of discolored, non-blanchable, deep red or maroon, or a blood-filled blister due to damage of underlying soft tissue from pressure or shear. It is a stage that is more appropriate for the described wound involving the epidermis and dermis.
Choice B rationale: Stage III pressure ulcers involve full-thickness tissue loss, but they do not involve the epidermis and dermis.
Choice C rationale: Unstageable ulcers are covered with slough or eschar, making it difficult to determine the depth of tissue involvement. In this case, the wound's description indicates involvement of the epidermis and dermis.
Choice D rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, not just the epidermis and dermis.
Correct Answer is C
Explanation
Choice A rationale: Leaning the client toward the wall may not provide sufficient support and could lead to a fall.
Choice B rationale: Assuming a narrow base of support does not provide adequate stability when a client is falling.
Choice C rationale: Lowering the client to the floor is a safety measure to prevent injury during a fall. It reduces the distance of the fall and minimizes the risk of injury.
Choice D rationale: Providing support by holding the client's arm may not be sufficient to prevent a fall. Lowering the client to the floor is a safer option.
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