A man with urinary incontinence tells the registered nurse he wears adult incontinence briefs for protection. What potential risks should the registered nurse discuss with this client?
Recurring skin breakdown and urinary tract infections.
Recurring foul odor and leakage of briefs.
Recurring inability to control urine output.
Recurring public embarrassment.
The Correct Answer is A
Skin breakdown:
Prolonged exposure to urine, especially in the presence of incontinence briefs, can irritate and macerate the skin, leading to breakdown.
Factors contributing to skin breakdown:
Moisture from urine:
Creates a warm, moist environment ideal for bacterial growth.
Disrupts the skin's natural barrier function, making it more susceptible to damage.
Friction from incontinence briefs:
Can rub against the skin, causing irritation and further damage.
Chemical irritants in urine:
Ammonia and other substances in urine can further irritate and damage the skin.
Signs of skin breakdown:
Redness, warmth, tenderness, or swelling of the skin.
Blisters, erosions, or ulcers.
Pain or discomfort.
Prevention of skin breakdown:
Frequent changing of incontinence briefs (as soon as they become wet or soiled).
Thorough cleansing of the skin with mild soap and water after each change.
Application of a skin barrier cream or ointment to protect the skin.
Use of breathable incontinence briefs that allow air to circulate.
Monitoring of the skin for signs of breakdown and seeking prompt medical attention if any occur. Urinary tract infections (UTIs):
Bacteria from the skin can enter the urinary tract through the urethra, leading to infection.
Factors increasing UTI risk in those with incontinence:
Incomplete bladder emptying:
Residual urine in the bladder provides a breeding ground for bacteria.
Use of incontinence briefs:
Can trap moisture and bacteria near the urethra.
Difficulty with personal hygiene:
May lead to the spread of bacteria from the skin to the urinary tract.
Signs of a UTI:
Frequent urination.
Pain or burning during urination.
Urgency to urinate.
Blood in the urine.
Cloudy or foul-smelling urine.
Prevention of UTIs:
Maintaining good personal hygiene.
Drinking plenty of fluids to help flush bacteria from the urinary tract.
Promptly emptying the bladder when the urge to urinate is felt.
Seeking medical attention if any signs of a UTI occur.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The physical dimension encompasses the tangible, biological aspects of an individual, including age, race, gender, genetic inheritance, anatomy, and physiological processes.
Here's a detailed breakdown of how each of these factors aligns with the physical dimension in the context of the patient's hypertension:
Age:
Hypertension is more prevalent in older adults due to natural changes in the cardiovascular system, such as stiffening of arteries and decreased elasticity.
The patient's age of 68 years places him within this higher-risk category.
Race:
African Americans have a disproportionately higher risk of hypertension and related complications compared to other racial groups.
This disparity is attributed to a complex interplay of genetic, environmental, and socioeconomic factors. Gender:
While both men and women experience hypertension, men tend to develop it earlier in life and have a higher lifetime risk.
This difference is partially due to hormonal influences and lifestyle factors.
Genetic inheritance:
Hypertension often has a significant genetic component.
Individuals with a family history of hypertension are more likely to develop the condition themselves, suggesting a role of inherited genes in blood pressure regulation.
Choice B rationale:
The emotional dimension focuses on psychological and mental aspects, including feelings, thoughts, behaviors, and coping mechanisms.
While emotions can certainly influence blood pressure and overall health, they are not directly categorized under the physical dimension in this context.
Choice C rationale:
The environmental dimension addresses external factors that impact health, such as access to healthcare, social support, exposure to pollutants, and community resources.
While these factors can indirectly contribute to hypertension risk, they are not inherent physical characteristics of the individual.
Choice D rationale:
The holistic dimension encompasses a comprehensive view of health, integrating physical, emotional, spiritual, social, and environmental aspects.
While holistic care is essential for managing hypertension, the question specifically asks about the dimension that age, race, gender, and genetic inheritance exemplify, which is most accurately aligned with the physical dimension.
Correct Answer is A
Explanation
Anatomy: The bladder is a hollow, muscular organ located in the lower abdomen, just behind the pubic bone. It stores urine until it is emptied through urination. The area between the symphysis pubis (the joint where the two pubic bones meet) and the umbilicus (belly button) is directly over the bladder, making it the most appropriate place to palpate for bladder distention.
Signs of bladder distention: When the bladder is distended, it can be felt as a firm, round mass in the lower abdomen. The patient may also experience discomfort, pressure, or an urge to urinate.
Nursing assessment: Palpation is a key nursing assessment skill used to evaluate the size, shape, and position of organs within the abdomen. In this case, palpation helps the nurse to determine if the bladder is distended and to assess the severity of the distention.
Clinical significance: Bladder distention can occur for a variety of reasons, including:
Postoperative urinary retention due to anesthesia or pain medications
Urinary tract obstruction (e.g., from a kidney stone or enlarged prostate)
Neurological conditions that affect bladder function (e.g., spinal cord injury, multiple sclerosis)
Dehydration
Certain medications (e.g., diuretics, anticholinergics)
Prompt intervention: Bladder distention can lead to complications such as urinary tract infections, kidney damage, and discomfort. It's important for the nurse to identify and address bladder distention promptly to prevent these complications.
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