A nurse is caring for a newly admitted client in the medical surgical department.

Exhibits

Which of the following findings from the admission assessment require immediate follow-up?

A. Mix different medications to save time: Combining medications without guidance increases the risk of drug interactions, overdosing, and harmful side effects. This practice is especially dangerous for older adults who often take multiple prescriptions.

B. Always consult healthcare providers before starting new medications: Older adults are at higher risk for polypharmacy complications and adverse drug interactions. Consulting with a healthcare provider ensures that new over-the-counter medications are safe, appropriate, and compatible with current prescriptions.

C. Avoid reading labels for potential side effects: Ignoring medication labels prevents patients from understanding dosing instructions, contraindications, and potential side effects. Reading labels is essential for safe and effective use of over-the-counter drugs.

D. Take medications with alcohol for enhanced effectiveness: Alcohol can interact dangerously with many medications, increasing the risk of sedation, liver damage, gastrointestinal bleeding, or impaired cognition. Combining alcohol and drugs is unsafe.

A. Functional incontinence: Functional incontinence occurs when physical or cognitive barriers prevent timely toileting, despite normal bladder function. This client demonstrates incomplete bladder emptying with significant residual urine.

B. Overflow incontinence: Overflow incontinence results from urinary retention and incomplete bladder emptying, leading to frequent dribbling and a sensation of bladder fullness. The bladder scan showing 300 mL post-void residual strongly supports this diagnosis, as the bladder remains distended even after voiding.

C. Urge incontinence: Urge incontinence is caused by overactive bladder contractions, leading to sudden, strong urges to urinate and involuntary leakage. It is not typically associated with high post-void residual volumes, making it less likely in this case.

D. Stress incontinence: Stress incontinence is leakage of urine during activities that increase intra-abdominal pressure, such as coughing or sneezing. It occurs due to weak pelvic floor muscles, not bladder retention, so high residual urine volume does not match this condition.