A nurse is caring for a client.

Exhibits

A nurse is reviewing a client's medical record. Select the 3 findings that place the client at risk for hearing impairment.

A. Reflex incontinence: Reflex incontinence occurs when the bladder muscle contracts and urine leaks out (often in large amounts) without any warning or urge. This is common in clients with nerve damage or spinal cord injuries, making it the correct answer.

B. Urge incontinence: Urge incontinence is characterized by a sudden, intense urge to urinate followed by involuntary urine loss. It is often associated with an overactive bladder, not nerve damage.

C. Stress incontinence: Stress incontinence involves urine leakage during physical activity or exertion (e.g., coughing, sneezing) that increases abdominal pressure. It is not typically related to nerve damage.

D. Overflow incontinence: Overflow incontinence occurs when the bladder is unable to empty properly, leading to dribbling of urine. It is often seen in conditions where the bladder muscles are weak or there is an obstruction. While it can be related to nerve damage, reflex incontinence is more accurate for this scenario.

A. Moist skin: Dehydration typically causes dry skin due to reduced fluid volume, not moist skin. This finding is not expected in a dehydrated client.

B. Dark-colored urine: Dark-colored urine is a common sign of dehydration, as the urine becomes more concentrated when the body conserves water. This finding is expected.

C. Distended neck veins: Dehydration typically causes flat or collapsed neck veins due to decreased blood volume. Distended neck veins are more associated with fluid overload or heart failure. This finding is not expected.

D. High blood pressure: Dehydration often leads to low blood pressure due to reduced blood volume. High blood pressure is not typically associated with dehydration.