A nurse is caring for a client who is postoperative and reports frequent leakage of small amounts of urine. The nurse notes that the client’s bladder is palpable upon examination. The nurse should identify these findings as which of the following forms of incontinence?
Stress
Urge
Functional
Overflow
The Correct Answer is D
Choice A Reason:
Stress incontinence occurs when urine leaks due to pressure on the bladder from activities such as coughing, sneezing, laughing, or exercising. It is typically associated with weakened pelvic floor muscles or urethral sphincter deficiency. However, it does not usually involve a palpable bladder or frequent leakage of small amounts of urine.
Choice B Reason:
Urge incontinence, also known as overactive bladder, is characterized by a sudden, intense urge to urinate followed by involuntary loss of urine. This condition is often caused by involuntary bladder contractions. While it involves frequent urination, it does not typically present with a palpable bladder.
Choice C Reason:
Functional incontinence occurs when a person is unable to reach the toilet in time due to physical or mental impairments, such as severe arthritis or dementia. This type of incontinence is not related to bladder function itself and does not involve a palpable bladder.
Choice D Reason:
Overflow incontinence is characterized by the frequent leakage of small amounts of urine due to an overfilled bladder that cannot empty completely. This condition often results in a palpable bladder upon examination, as the bladder remains distended with urine. It is commonly seen in postoperative clients or those with conditions that obstruct urine flow or impair bladder emptying.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
Choice A Reason:
Initiating an insulin drip is not a standard intervention for all clients with acute pancreatitis. This intervention is typically reserved for clients who develop hyperglycemia or diabetes as a complication of pancreatitis. Acute pancreatitis can affect the pancreas’ ability to produce insulin, but not all clients will require an insulin drip.
Choice B Reason:
Monitoring blood glucose levels is crucial for clients with acute pancreatitis because the pancreas plays a key role in regulating blood sugar. Inflammation or damage to the pancreas can lead to fluctuations in blood glucose levels, making regular monitoring essential to manage potential hyperglycemia or hypoglycemia.
Choice C Reason:
Continuing a regular diet as tolerated is not appropriate for clients with acute pancreatitis. These clients are typically kept NPO (nothing by mouth) to rest the pancreas and reduce the secretion of pancreatic enzymes, which can exacerbate inflammation and pain.
Choice D Reason:
Maintaining NPO status until the client is pain-free is a standard intervention for acute pancreatitis. This approach helps to rest the pancreas and prevent the release of digestive enzymes that can further inflame the pancreas. Once the client is pain-free and inflammation has subsided, a gradual reintroduction of oral intake can be considered.
Choice E Reason:
Managing acute pain is a critical aspect of care for clients with acute pancreatitis. Pain management can include medications such as opioids, as well as non-pharmacological interventions like positioning and relaxation techniques. Effective pain management improves the client’s comfort and can help reduce stress on the pancreas.
Correct Answer is B
Explanation
Choice A Reason:
Decreasing leg strength is a common symptom of Guillain-Barré syndrome (GBS) and indicates the progression of muscle weakness. While it is concerning and should be monitored, it is not as immediately critical as respiratory complications.
Choice B Reason:
Decreasing voice volume can indicate involvement of the cranial nerves and potential respiratory muscle weakness, which can lead to respiratory failure. This is an urgent finding that requires immediate attention to prevent respiratory complications.
Choice C Reason:
Decreased deep tendon reflexes are a hallmark of GBS and are expected in the progression of the disease. While they should be documented and monitored, they do not require immediate reporting unless accompanied by other critical symptoms.
Choice D Reason:
Decreased sensation in the arms is another common symptom of GBS due to peripheral nerve involvement. It should be monitored, but it is not as urgent as signs of respiratory compromise.
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