A nurse assessing a client’s notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence?

Reflex incontinence

Urge incontinence

Stress incontinence

Overflow incontinence

Answer and Explanation

The Correct Answer is D

A. Reflex incontinence occurs due to a neurological impairment where the bladder empties involuntarily without sensation of fullness (e.g., spinal cord injury). This client’s symptoms suggest retention rather than involuntary reflex voiding.

B. Urge incontinence is characterized by a sudden, strong urge to urinate followed by involuntary leakage, typically caused by an overactive bladder. This does not match the description of small, continuous leakage with bladder distention.

C. Stress incontinence is due to weakened pelvic muscles, leading to urine leakage during activities like coughing, sneezing, or laughing. This does not describe constant leakage with a distended bladder.

D. Overflow incontinence occurs when the bladder becomes overly full due to incomplete emptying, leading to continuous dribbling of urine. The presence of a distended and palpable bladder strongly supports this diagnosis.

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Free Nursing Study Resources

Correct Answer is ["740"]

Explanation

4 oz juice → 120 mL
6 oz tea → 180 mL
100 mL ice chips → 50 mL (Ice chips are counted as half their volume when melted)
IV bolus → 150 mL
8 oz broth → 240 mL

Total intake:

120+180+50+150+240=740mL120 + 180 + 50 + 150 + 240=740mL

Correct answer: 740 mL

A. "Excessive laxative use may cause an electrolyte imbalance." B. "Chronic use of laxatives can lead to a tear in the rectal mucosa." C. "Decrease your intake of foods high in fiber." D. "Irregular bowel movements are an indication of poor intestinal health."

Correct Answer is A

Explanation

A. "Excessive laxative use may cause an electrolyte imbalance." Chronic laxative use can lead to hypokalemia, dehydration, and other imbalances.

B. "Chronic use of laxatives can lead to a tear in the rectal mucosa." While irritation is possible, tearing (anal fissures) is more associated with straining or hard stools, not laxative overuse.

C. "Decrease your intake of foods high in fiber." Fiber helps regulate bowel movements and reduces laxative dependence.

D. "Irregular bowel movements are an indication of poor intestinal health." Bowel patterns vary by individual, and irregularity does not always indicate poor health.

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A nurse assessing a client’s notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing an 8-hr 1&0 record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

Correct Answer is ["740"]

Explanation

A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is educating a group of older adults in a community center on weight management using the BMI scale. Using the client's height and weight to calculate BMI, which of the following clients has a healthy BMI?

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?

A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

A nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply)

A nurse is caring for a client who is well-hydrated and who demonstrates no evidence of anemia. Which of the following laboratory values gives the nurse an assessment of the adequacy of the client's protein uptake and synthesis?

A nurse is reviewing urinary laboratory results. Which finding will cause the nurse to follow up?

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