An 85-year-old client is experiencing uncontrollable leakage of urine with a strong desire to void and even leaks on the way to the toilet. Which priority nursing diagnosis will the nurse include in the client's plan of care?

Functional urinary incontinence

Urinary retention

Urge urinary incontinence

Impaired skin integrity

Answer and Explanation

The Correct Answer is C

A. Functional urinary incontinence: This occurs when mobility or cognitive impairments prevent the client from reaching the toilet in time. Since this client has a strong urge to void, functional incontinence is not the best fit.

B. Urinary retention: Urinary retention is the inability to empty the bladder completely, often leading to overflow incontinence. However, this client experiences urgency and leakage, not retention.

C. Urge urinary incontinence: This occurs when a strong, sudden urge to urinate leads to involuntary leakage before reaching the toilet. It is often due to overactive bladder or neurological issues.

D. Impaired skin integrity: While prolonged incontinence can lead to skin breakdown, the primary diagnosis should address the cause of incontinence rather than a secondary complication.

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Correct Answer is A

Explanation

A. "You may have pink-tinged urine after this procedure." Minor bleeding and pink-tinged urine are expected due to irritation of the urethra and bladder mucosa during the procedure.

B. "You should limit fluids for 12 hr following the procedure." Fluids should be encouraged to help flush the bladder and prevent infection or clot formation.

C. "You will be placed on your right side during the procedure." Cystoscopy is performed with the client in the lithotomy position (on the back with legs supported in stirrups).

D. "You can eat a full liquid meal up to 1 hour before the procedure."Cystoscopy may require sedation, and clients are typically instructed to be NPO (nothing by mouth) for several hours before the procedure.

A. Stoma is purple B. Stoma is moist. C. Stoma is flush with the skin D. Stoma is protruding from the abdomen

Correct Answer is A

Explanation

A. Stoma is purple. A purple, dusky, or black stoma indicates poor blood circulation, possibly due to ischemia or necrosis. This is a surgical emergency requiring immediate attention.

B. Stoma is moist. Normal finding, indicating adequate perfusion.

C. Stoma is flush with the skin. Possible but not necessarily abnormal. However, a retracted stoma (sunken below skin level) could lead to leakage and skin irritation.

D. Stoma is protruding from the abdomen. Normal in the early postoperative period. A slight protrusion (bud-like shape) is expected. However, significant prolapse (excessive protrusion) may need evaluation.

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An 85-year-old client is experiencing uncontrollable leakage of urine with a strong desire to void and even leaks on the way to the toilet. Which priority nursing diagnosis will the nurse include in the client's plan of care?

Nursing Test Bank

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