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 A
Explanation
Choice A Reason:
Provide assistance with ambulation: Patients with cerebellar tumors often experience ataxia, which is a lack of muscle coordination affecting voluntary movements such as walking and balance. Assisting with ambulation is crucial to prevent falls and ensure the patient’s safety. The cerebellum plays a significant role in motor control, and damage to this area can severely impair a patient’s ability to move safely. Therefore, providing assistance with ambulation is a priority to prevent injury and promote mobility.
Choice B Reason:
Facilitate retention of facts by repeating instructions: While repeating instructions can be beneficial for patients with cognitive impairments, it is not the primary concern for a patient with a cerebellar tumor. The main issues with cerebellar tumors are related to motor control and balance. Although cognitive support is important, ensuring physical safety through assistance with ambulation takes precedence.
Choice C Reason:
Place the client in a darkened room: Placing a patient in a darkened room might help with symptoms like photophobia (sensitivity to light), but it does not address the primary concerns associated with cerebellar tumors, such as balance and coordination. This action does not directly contribute to the patient’s immediate safety and mobility needs.
Choice D Reason:
Speak slowly and clearly: Clear communication is always important in nursing care, especially for patients who may have difficulty understanding due to neurological issues. However, for a patient with a cerebellar tumor, the immediate priority is to address motor dysfunction and prevent falls. Speaking slowly and clearly is supportive but not the primary action needed to ensure the patient’s safety.
Correct Answer is B
Explanation
Choice A Reason:
Suctioning secretions from the endotracheal tube is a common intervention for high-pressure alarms, which indicate an obstruction in the airway. However, a low-pressure alarm typically signals a disconnection or leak in the ventilator system, not an obstruction.
Choice B Reason:
Checking the ventilator tubing connections is the appropriate response to a low-pressure alarm. This alarm usually indicates a disconnection or leak in the ventilator circuit, which can compromise the delivery of adequate ventilation to the patient. Ensuring all connections are secure is the first step in troubleshooting this issue.
Choice C Reason:
Administering intravenous sedation and analgesia is not directly related to addressing a low-pressure ventilator alarm. While sedation may be necessary for patient comfort and to prevent agitation, it does not resolve the underlying issue of a disconnection or leak in the ventilator system.
Choice D Reason:
Reassuring the client and instructing them not to bite on the tube is more relevant to high-pressure alarms, where patient actions such as biting the tube can cause increased airway resistance. It does not address the cause of a low-pressure alarm, which is typically due to a disconnection or leak.
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