A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence?

Overflow incontinence

Urge incontinence

Stress incontinence

Reflex incontinence

Answer and Explanation

The Correct Answer is D

Choice A reason: Overflow incontinence is not the type of urinary incontinence that the client is experiencing. Overflow incontinence occurs when the bladder is overfilled and cannot empty properly, causing frequent or constant dribbling of urine. It can be caused by a blockage in the urinary tract, such as an enlarged prostate or a kidney stone, or by a weak bladder muscle that cannot contract enough to empty the bladder.

Choice B reason: Urge incontinence is not the type of urinary incontinence that the client is experiencing. Urge incontinence occurs when the bladder muscle contracts involuntarily and causes a sudden and strong urge to urinate, followed by an involuntary loss of urine. It can be caused by an infection, a neurological disorder, or an overactive bladder.

Choice C reason: Stress incontinence is not the type of urinary incontinence that the client is experiencing. Stress incontinence occurs when the pelvic floor muscles or the urethral sphincter are weakened or damaged and cannot hold urine in the bladder when there is increased abdominal pressure, such as from coughing, sneezing, laughing, or exercising. It can be caused by pregnancy, childbirth, menopause, or surgery.

Choice D reason: Reflex incontinence is the type of urinary incontinence that the client is experiencing. Reflex incontinence occurs when the bladder muscle contracts without the sensation or control of the person, causing urine to leak without warning or awareness. It can be caused by nerve damage that affects the communication between the bladder and the brain, such as from a spinal cord injury, a stroke, or multiple sclerosis..

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Correct Answer is A

Explanation

Choice A reason: Ask the client to read a Snellen chart. This method is used to assess cranial nerve II, which is the optic nerve. The optic nerve is responsible for vision and visual acuity. A Snellen chart is a tool that displays letters of different sizes and measures how well the client can see them from a distance of 20 feet.

Choice B reason: Ask the client to clench his teeth. This method is not used to assess cranial nerve II, but cranial nerve V, which is the trigeminal nerve. The trigeminal nerve is responsible for sensation and motor function of the face, mouth, and jaw. Clenching the teeth tests the strength and symmetry of the masseter and temporalis muscles, which are innervated by the trigeminal nerve.

Choice C reason: Listen to the client’s speech. This method is not used to assess cranial nerve II, but cranial nerves IX, X, and XII, which are the glossopharyngeal, vagus, and hypoglossal nerves. These nerves are responsible for speech production and swallowing. Listening to the client’s speech tests the quality, clarity, and articulation of the voice, as well as the movement and coordination of the tongue and palate.

Choice D reason: Ask the client to identify scented aromas. This method is not used to assess cranial nerve II, but cranial nerve I, which is the olfactory nerve. The olfactory nerve is responsible for smell and olfaction. Asking the client to identify scented aromas tests the ability to detect and recognize different odors.

A. Hyperthermia B. Absence of bowel sounds C. Polyuria D. Weakened gag reflex E. Hypotension

Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Hyperthermia. This answer is incorrect because hyperthermia is not a complication of a cervical spinal cord injury, but rather a condition that can worsen the injury. Hyperthermia can increase the metabolic demand and oxygen consumption of the injured spinal cord, leading to more damage and inflammation.

Choice B reason: Absence of bowel sounds. This answer is correct because absence of bowel sounds is a complication of a cervical spinal cord injury, which can affect the autonomic nervous system and impair the function of the gastrointestinal system. A cervical spinal cord injury can cause spinal shock, which leads to decreased peristalsis and paralytic ileus.

Choice C reason: Polyuria. This answer is incorrect because polyuria is not a complication of a cervical spinal cord injury, but rather a condition that can occur after the resolution of spinal shock. Polyuria can result from the loss of sympathetic control over the renal system, leading to increased urine output and decreased antidiuretic hormone secretion.

Choice D reason: Weakened gag reflex. This answer is correct because weakened gag reflex is a complication of a cervical spinal cord injury, which can affect the autonomic nervous system and impair the function of the respiratory system. A cervical spinal cord injury can cause damage to the cranial nerves that control the gag reflex, leading to difficulty swallowing, aspiration, and pneumonia.

Choice E reason: Hypotension. This answer is correct because hypotension is a complication of a cervical spinal cord injury, which can affect the autonomic nervous system and impair the function of the cardiovascular system. A cervical spinal cord injury can cause neurogenic shock, which leads to decreased sympathetic tone, vasodilation, and reduced cardiac output.

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A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client’s cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?

Correct Answer is A

Explanation

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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