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

Answer and Explanation

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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Correct Answer is B

Explanation

A. "Don't worry, most clients dislike the prep more than the procedure itself." This dismisses the client's concerns rather than addressing them directly.

B. "Before the examination, your provider will give you a sedative that will make you sleepy." This response reassures the client by providing factual information about sedation during the procedure.

C. "After you have signed the consent form, we can talk more about this." This does not directly address the client’s anxiety.

D. "I know you're anxious, but this procedure is recommended for people your age." While screening is important, this response does not alleviate the client’s concerns.

Correct Answer is ["0.8"]

Explanation

Heparin 3,800 units is prescribed.

Available concentration: 5,000 units/mL.

Dose to administer=Ordered Dose / Available concentration

=3800 / 5000

= 0.76mL

Rounded to the nearest tenth: 0.8 mL.

Correct Answer: 0.8 mL

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving heparin 3,800 units subcutaneous daily. Available is heparin 5,000 units/mL. How many ml. should the nurse administer? (Round the answer to the nearest tenth.)

Correct Answer is ["0.8"]

Explanation

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?

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