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?
Functional urinary incontinence
Urinary retention
Urge urinary incontinence
Impaired skin integrity
The Correct Answer is C
A. Functional urinary incontinence: This occurs when mobility or cognitive impairments prevent the client from reaching the toilet in time. Since this client has a strong urge to void, functional incontinence is not the best fit.
B. Urinary retention: Urinary retention is the inability to empty the bladder completely, often leading to overflow incontinence. However, this client experiences urgency and leakage, not retention.
C. Urge urinary incontinence: This occurs when a strong, sudden urge to urinate leads to involuntary leakage before reaching the toilet. It is often due to overactive bladder or neurological issues.
D. Impaired skin integrity: While prolonged incontinence can lead to skin breakdown, the primary diagnosis should address the cause of incontinence rather than a secondary complication.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Cleanse the skin with antibacterial soap and apply talcum powder to the buttock." Antibacterial soap can be too harsh for the skin, and talcum powder is not recommended because it does not provide an effective moisture barrier.
B. "Initiate a bowel or habit training program to promote continence." A scheduled toileting program helps establish a routine and reduce episodes of incontinence.
C. "Use sanitary pads in the patient's underwear." While absorbent products may be used, they do not address the underlying issue or promote continence.
D. "Help the patient go to the toilet once every hour." Frequent toileting may be impractical and unnecessary. Habit training with scheduled bathroom times is more effective.
Correct Answer is A
Explanation
A. "Take the medication with a full glass of water." Docusate is a stool softener that works best when taken with plenty of fluids.
B. "Expect abdominal pain with this medication." Docusate should not cause abdominal pain; if it does, it should be discontinued.
C. "Take this medication on an empty stomach." Docusate can be taken with or without food.
D. "Do not take this medication before bedtime." It is often recommended before bedtime to work overnight.
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