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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A Reason

Axillary temperature 37.2° C (99° F). This temperature is within the normal range and does not indicate an immediate need for intervention. Normal body temperature ranges from 36.1° C to 37.2° C (97° F to 99° F).

Choice B Reason

Apical pulse 100/min. While a pulse rate of 100 beats per minute is on the higher end of the normal range, it is not necessarily indicative of an immediate life-threatening condition. Normal resting heart rate for adults ranges from 60 to 100 beats per minute.

Choice C Reason

Respiratory rate 30/min. This is the correct answer. A respiratory rate of 30 breaths per minute is significantly higher than the normal range of 12 to 20 breaths per minute for adults. This could indicate respiratory distress or other complications that require immediate intervention.

Choice D Reason

Blood pressure 140/84 mm Hg. While this blood pressure reading is elevated and may require monitoring, it does not indicate an immediate life-threatening condition. Normal blood pressure is typically around 120/80 mm Hg, but a reading of 140/84 mm Hg is not uncommon and can be managed with appropriate care.

A. Use an electric shaver. B. Avoid crowds. C. Take temperature weekly. D. Consume a low-residue diet. E. Monitor for bruising.

Correct Answer is ["A","B","E"]

Explanation

Choice A Reason:

Using an electric shaver is recommended for clients who have received chemotherapy because it reduces the risk of cuts and bleeding. Chemotherapy can lower platelet counts, leading to an increased risk of bleeding. Traditional razors can cause nicks and cuts, which can be problematic for clients with low platelet counts.

Choice B Reason:

Avoiding crowds is crucial for clients who have received chemotherapy because their immune systems are often weakened, making them more susceptible to infections. Crowded places increase the risk of exposure to pathogens, which can lead to serious infections in immunocompromised individuals.

Choice C Reason:

Taking temperature weekly is not sufficient for clients who have received chemotherapy. These clients are at a higher risk of infections, and any sign of fever should be monitored closely. It is generally recommended to take the temperature daily or more frequently if the client feels unwell.

Choice D Reason:

Consuming a low-residue diet is not typically necessary for clients who have received chemotherapy unless they are experiencing specific gastrointestinal issues. A balanced diet with adequate nutrients is usually recommended to support overall health and recovery.

Choice E Reason:

Monitoring for bruising is important for clients who have received chemotherapy because it can indicate low platelet counts or other bleeding disorders. Early detection of bruising can help in managing and preventing more serious bleeding complications.

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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?

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