A nurse is caring for an older adult client who is experiencing urinary incontinence. Which of the following client statements indicates the client has overflow incontinence?

"My urine comes out whenever I sneeze."

"It seems like my bladder empties without warning."

"I have urine incontinence whenever I take a diuretic."

"My urine seems to dribble out frequently."

Answer and Explanation

The Correct Answer is D

A. "My urine comes out whenever I sneeze": This indicates stress incontinence, where urine leakage occurs with physical activities that increase abdominal pressure.
B. "It seems like my bladder empties without warning": This suggests urge incontinence, characterized by a sudden and intense urge to urinate.
C. "I have urine incontinence whenever I take a diuretic": This statement is more related to the effects of diuretics rather than a specific type of urinary incontinence.
D. "My urine seems to dribble out frequently": This is characteristic of overflow incontinence, where the bladder becomes overfilled and urine dribbles out due to inadequate emptying.

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Correct Answer is C

Explanation

A. "You will not become fatigued when you use assistive devices": This is incorrect as clients may still experience fatigue even with assistive devices, and energy conservation strategies should be discussed.
B. "Plan to hire a home care aide to perform all of your ADLs": This is not advisable as the goal is to encourage as much independence as possible; assistance should be provided based on need, not all tasks.
C. "Install grab bars in your shower to assist with your balance": This is correct as installing grab bars can enhance safety and support the client’s balance, helping to prevent falls and injuries.
D. "Place a towel in the shower to prevent slipping": This is not as effective as grab bars and may not provide adequate support or prevent slips as well as proper bathroom modifications.

A. The skin around the client's stoma is bulging. B. The client has had no fecal output from the stoma. C. The stoma protrudes 2 cm (0.8 in) above client's abdominal wall. D. The client's stoma is moist and beefy red.

Correct Answer is B

Explanation

A. The skin around the client's stoma is bulging: While bulging skin can be concerning, it is often a normal postoperative finding as the stoma settles into its new position. However, further evaluation may be needed if other symptoms are present.
B. The client has had no fecal output from the stoma: This is correct as the absence of fecal output 24 hours postoperatively could indicate a potential issue such as a blockage or anastomotic failure, which requires prompt evaluation by the provider.
C. The stoma protrudes 2 cm (0.8 in) above client's abdominal wall: This is generally considered normal. The stoma should protrude slightly to ensure it is not retracted and is functioning properly.
D. The client's stoma is moist and beefy red: This is a normal finding. A healthy stoma should be moist and beefy red, indicating good blood flow and viability.

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A nurse is caring for an older adult client who is experiencing urinary incontinence. Which of the following client statements indicates the client has overflow incontinence?

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