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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Sigmoid. The sigmoid colon is the last part of the intestine, where stool is more solid and formed.
B. Transverse. Stool in a transverse colostomy is semi-formed or pasty.
C. Ascending. An ascending colostomy produces very liquid stool because it is located near the beginning of the large intestine, where water absorption is minimal.
D. Descending. Stool in a descending colostomy is more solid and formed compared to the ascending and transverse colostomies.
Correct Answer is D
Explanation
A. Chew the sucralfate thoroughly before swallowing. Sucralfate should be swallowed whole or dissolved in water, not chewed.
B. Take sucralfate with a full glass of milk. Milk can interfere with the medication’s effectiveness.
C. Take an antacid with sucralfate. Antacids should be taken separately to avoid interaction.
D. Allow a 2-hour interval between these medications. Sucralfate can interfere with phenytoin absorption, so they should be spaced apart.
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