A nurse is caring for a client who tells the nurse she experiences urinary incontinence when she sneezes. The nurse recognizes this is an expected finding for which of the following types of incontinence?

Stress incontinence

Urge incontinence

Overflow incontinence

Reflex incontinence

Answer and Explanation

The Correct Answer is A

A. Stress incontinence

Stress incontinence is the involuntary loss of urine during activities that increase intra-abdominal pressure, such as sneezing, coughing, laughing, or lifting heavy objects. In stress incontinence, the pelvic floor muscles are weakened, leading to inadequate support of the bladder and urethra. This results in leakage of urine during moments of increased pressure on the bladder.

B. Urge incontinence

Urge incontinence involves a strong and sudden urge to urinate, leading to involuntary urine loss. It is often associated with an overactive bladder and may not be related to increased abdominal pressure.

C. Overflow incontinence

Overflow incontinence occurs when the bladder is unable to empty completely, leading to constant dribbling of urine. It is often associated with conditions that obstruct urine flow, such as an enlarged prostate in men.

D. Reflex incontinence

Reflex incontinence is characterized by the involuntary loss of urine due to a reflex arc that bypasses normal control mechanisms. It is often associated with neurological conditions that affect bladder control.

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Correct Answer is C

Explanation

A. Massage the client’s bony prominences:

Massaging bony prominences is generally not recommended for individuals at risk for pressure ulcers. Massage can increase friction and shear forces on the skin, which may contribute to skin damage rather than prevent it. Gentle, careful handling of the skin is preferable.

B. Keep the head of the bed elevated:

While elevating the head of the bed may be appropriate for certain medical conditions, it is not a primary preventive measure for pressure ulcers. In fact, keeping the head of the bed elevated continuously can contribute to pressure on the sacrum and coccyx, increasing the risk of pressure ulcers in those areas.

C. Reposition the client at least every 2 hr:

Regular repositioning is a crucial preventive measure for pressure ulcers. Repositioning helps redistribute pressure, improves blood flow to vulnerable areas, and reduces the risk of skin breakdown.

D. Keep the client’s skin moist:

While maintaining skin moisture is important to prevent dryness and cracking, excessive moisture can contribute to skin breakdown. The emphasis should be on keeping the skin clean and dry, with the use of moisturizers applied judiciously to prevent excessive dryness.

A. Provide a diet high in protein. B. Provide ibuprofen for retroperitoneal discomfort. C. Monitor intake and output hourly D. Encourage the client to consume at least 2 L of fluid daily

Correct Answer is C

Explanation

A. Provide a diet high in protein.

During the oliguric phase of acute kidney injury (AKI), there is a risk of electrolyte imbalances, including elevated levels of blood urea nitrogen (BUN) and creatinine. Restricting protein intake is often recommended during this phase to manage azotemia and prevent the accumulation of waste products that the kidneys may struggle to excrete.

B. Provide ibuprofen for retroperitoneal discomfort.

Ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated in AKI. They can further compromise renal function and may contribute to acute tubular necrosis. NSAIDs can also affect renal blood flow, leading to worsening kidney function.

C. Monitor intake and output hourly.

Monitoring intake and output (I&O) is a critical nursing intervention during the oliguric phase of AKI. Hourly monitoring helps assess renal function, fluid balance, and the effectiveness of interventions. It allows for early detection of changes that may require prompt intervention.

D. Encourage the client to consume at least 2 L of fluid daily.

In the oliguric phase of AKI, fluid intake is often restricted to prevent fluid overload. Encouraging excessive fluid intake may contribute to fluid retention and worsen the oliguria. Fluid management is carefully regulated based on the individual client's needs and renal function.

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A nurse is caring for a client who tells the nurse she experiences urinary incontinence when she sneezes. The nurse recognizes this is an expected finding for which of the following types of incontinence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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