The nurse is interviewing a client who states the presence of urinary incontinence with coughing and sneezing.
The nurse would correctly document this type of incontinence as which of the following?

Functional.

Reflex.

Stress.

Urge.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Functional incontinence occurs when an individual cannot reach the bathroom in time due to physical or cognitive limitations. It is not related to stress or pressure on the bladder but rather to external factors that impede timely access to toileting facilities.

Choice B rationale

Reflex incontinence is characterized by involuntary loss of urine due to a lack of signal awareness or detrusor muscle overactivity. It is typically associated with neurological conditions such as spinal cord injuries or multiple sclerosis. This type of incontinence does not involve stress-related triggers like coughing or sneezing.

Choice C rationale

Stress incontinence involves the involuntary leakage of urine during activities that increase intra-abdominal pressure, such as coughing, sneezing, laughing, or physical exertion. This type of incontinence is commonly seen in women, particularly after childbirth or during menopause, due to weakened pelvic floor muscles or sphincter dysfunction.

Choice D rationale

Urge incontinence is characterized by a sudden and intense urge to urinate, often resulting in involuntary urine leakage before reaching the bathroom. It is typically caused by overactive bladder muscles or nerve signals and is not specifically triggered by actions like coughing or sneezing.

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Correct Answer is B

Explanation

Choice A rationale

5th ICS Left MCL is the location for the apical impulse (point of maximal impulse), not Erb's Point.

Choice B rationale

Erb's Point is located at the 3rd ICS Left SB and is significant for auscultation of heart sounds, particularly the S1 and S2 sounds.

Choice C rationale

2nd ICS Left SB is the location for auscultating the pulmonic valve area.

Choice D rationale

4th ICS Left SB is where the tricuspid valve is auscultated.

A. The nurse will understand the unaffected ear will show lateralization to the Weber's test. B. Place the activated tuning fork to the mid skull and ask if the patient can hear it louder in either ear. C. Place the activated tuning fork to the patient's mastoid bone first then place over air. D. Place the activated tuning fork to the client's ear over the mastoid bone then activate it again over the air.

Correct Answer is B

Explanation

Choice A rationale

Lateralization to the unaffected ear in Weber's test actually indicates sensorineural hearing loss in the affected ear. This choice is incorrect as it doesn’t describe the correct procedure for the test.

Choice B rationale

The Weber's test involves placing an activated tuning fork in the midline of the skull and asking the patient if the sound is heard more loudly in either ear. This helps determine if there is lateralization, which is key in diagnosing the type of hearing loss. Thus, this is the correct procedure for the test.

Choice C rationale

Placing the tuning fork on the mastoid bone and then over air is actually part of the Rinne test, not the Weber test. This choice is, therefore, incorrect for the Weber test.

Choice D rationale

Similar to Choice C, this process describes the Rinne test, which compares air conduction and bone conduction of sound. This is not the correct method for performing Weber’s test.

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The nurse is interviewing a client who states the presence of urinary incontinence with coughing and sneezing.The nurse would correctly document this type of incontinence as which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The instructor asks the student nurse to auscultate the client's Erb's Point. Where is the cardiac landmark referred to as the Erb's Point located?

Correct Answer is B

Explanation

The nurse plans to assess the client's hearing.What action should the nurse take when performing the Weber's test?

Correct Answer is B

Explanation

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment.On assessment the nurse might expect to see which finding?

The nurse is speaking to the client and suspects a weakness in eye muscle after observing the eyes cross.What test should the nurse administer to further assess this problem?

A nurse is auscultating the breath sounds of a client who has chronic obstructive pulmonary disease.When the client exhales, the nurse hears continuous high-pitched whistling sound.The nurse should document this as?

The nurse is examining an elderly client and notes an exaggerated curvature of the thoracic spine.The nurse should document this finding as which of the following?

On assessment of the client's tongue, the client is unable to protrude the tongue and has poor strength on testing against resistance.This would indicate dysfunction of which cranial nerve?