5.B: Bladder Incontinence and Retention

The nurse is caring for a client with newly diagnosed urinary retention. The nurse should question a medication order that falls into which​ classification?

- Anticholinergic ​Rationale: An anticholinergic agent is contraindicated in the client with urinary retention. Anticholinergics affect the autonomic nervous system and interfere with the normal urination process leading to the retention of urine.​ Diuretics, cholinergic​ agents, and antiflatulence agents are not contraindicated in urinary retention.

The nurse is caring for a newborn infant who has not yet voided in the first 48 hours of life. Which action should the nurse​ take?

- Assess for bladder distention Rationale: Bladder distention should be assessed in the newborn who has not yet voided in the first 48 hours of life. Actions should also include notifying the healthcare provider and assessing fluid​ status, not waiting another 24 hours. IV fluid and urinary catheterization would not be initiated without healthcare provider orders.

The home health nurse is visiting an older adult client. The nurse notices the scent of urine and the client states difficulty with urinary continence. Which intervention should the nurse​ implement?

- Assess mobility and bathroom access. Rationale: In older​ age, decreased mobility contributes to urinary incontinence. A urinary catheter would be indicated for urinary retention.​ Around-the-clock care and fluid restriction are not therapeutic interventions for urinary continence.

The nurse is planning care for the client with urinary incontinence. Which goal should be included in the care​ plan? (Select all that​ apply.)

- Avoiding infection - Preventing skin breakdown - Exhibiting solid​ self-esteem - Restoring a normal voiding pattern ​Rationale: Avoiding​ infection, preventing skin​ breakdown, maintaining​ self-esteem, and establishing a normal voiding pattern are all goals in the care of the client with urinary incontinence. Assistive devices may be necessary to help​ voiding, particularly with​ mobility, so toileting with a device may not be a goal of care in all scenarios.

The mother of a​ 3-year-old child is concerned about continued urinary incontinence of the child at night and asks the nurse what she should do. Which information should the nurse include in teaching this​ mother?

- Control of the bladder during the night will follow control of the bladder during the day between the ages of 2 and 5. ​Rationale: Control of the bladder during the night will follow control of the bladder during the day between the ages of 2 and 5. Control of the bladder during the night is related to maturation of the muscles.

The nurse case manager is preparing a client for discharge. The client has been successfully taught​ self-catheterization for urinary retention related to neurogenic bladder. Which other collaborative partner does the nurse​ involve? (Select all that​ apply.)

- Family - infection control nurse to prevent​ UTI - home health delivery of catheter devices ​Rationale: The client who is performing​ self-catheterization at home could use the support of​ family, education from an infection control nurse to prevent​ UTI, and home health delivery of catheter devices. An ostomy nurse is not​ needed, because there is no​ wound, and there is no indication of need for a home health aide.

The nurse is assessing a client who complains of urine leakage when laughing or coughing. Which urinary disorder should the nurse​ suspect?

- Incontinence Rationale: The clinical manifestation of urinary incontinence is uncontrolled leakage of urine. Oliguria is a decrease in urine​ production, and polyuria is an increase in urine production. Urinary retention is the failure to empty the bladder.

The nurse caring for a client with stress incontinence should identify which condition as a​ cause?

- Pelvic muscle​ relaxation, a weak​ urethra, and surrounding tissues cause decreased urethral resistance. ​Rationale: Stress incontinence occurs when the pelvic muscle relaxes and a weak urethra and surrounding tissues cause decreased urethral resistance. Urge incontinence is when an overactive detrusor muscle increases bladder pressure. Overflow incontinence is when the lack of normal detrusor muscle function causes bladder overfilling and increased bladder pressure. Functional incontinence occurs when the client is unable to respond to the need to urinate. OK

The nurse is caring for a client with urinary retention. Which action should the nurse include to promote normal​ voiding? (Select all that​ apply.)

- Sitz bath - Providing privacy - Running water - Running warm water over the perineum ​Rationale: A sitz​ bath, privacy, and running water all promote normal voiding. Running warm​ water, not cool​ water, over the perineum promotes voiding. Lying flat is not a normal position for​ voiding, so it does not promote voiding.

The nurse is preparing health education for men about urinary retention and urinary incontinence. Which statement should the nurse​ include?

- Urinary incontinence is often associated with treatment for prostate​ enlargement ​Rationale: More than half of men over 60 report urinary incontinence with treatment of prostate enlargement. Urinary retention is more common in men than it is in women and less common than is urinary incontinence. Urinary retention and incontinence are often associated with prostate issues in the​ male, not kidney​ failure, which may manifest as oliguria or anuria.

The nurse is providing care to older adult clients at a​ long-term care facility. Which factor places these clients at risk for urinary​ incontinence? (Select all that​ apply.)

- age - stroke - depression - more than two urinary tract infections​ (UTIs) in a year ​Rationale: Risk factors for urinary incontinence include​ age, gender​ (women are more susceptible than are​ men), obesity,​ smoking, diabetes,​ inactivity, pregnancy,​ depression, neurologic disorders​ (e.g., stroke), two or more UTIs per​ year, and medications​ (medications affecting the adrenergic​ system, diuretics, and calcium channel​ blockers). Kegel exercises decrease the risk of urinary incontinence.

The nurse caring for a client with incontinence should consider the client at risk for low​ self-esteem and social isolation for which​ reason?

- it is considered socially unacceptable ​Rationale: Urinary incontinence is considered socially unacceptable.​ Therefore, it can be physically and emotionally distressing.​ Oftentimes, the client is embarrassed about dribbling or having an accident and may therefore restrict normal activities.

Which risk factor should the nurse assess in a client with bladder​ incontinence? (Select all that​ apply.)

- obesity - depression - medications that affect the adrenergic system - two or more urinary tract infections​ (UTIs) per year Rationale: Risk factors for urinary incontinence include two or more UTIs per​ year, medications that affect the adrenergic​ systems, depression, and obesity. Clients should eat a​ high-fiber diet to prevent​ constipation, which is a risk factor for incontinence.

A client who has experienced a stroke is struggling with urinary continence due to difficulty with manipulating clothing at the toilet. Which collaborative team member would benefit this​ client's management of​ incontinence?

- occupational therapist Rationale: The occupational therapist can assist the client with fine motor​ skills, mobility, and adaptive devices with clothing to help prevent urinary incontinence. The ostomy nurse would assist with wound care. The infection control nurse would assist with infection prevention. The radiologist interprets imaging as a diagnostic tool.

The nurse is completing an assessment on a client. Which assessment finding supports the suspicion of urinary​ incontinence? (Select all that​ apply.)

- odor of urine - soiled clothing - Irritated perineal tissue - Frequent bathroom breaks ​Rationale: The odor of​ urine, soiled​ clothing, irritated perineal​ tissue, and frequent bathroom breaks all support suspicion of leakage of urine from urinary incontinence.​ Weak, not​ strong, pelvic floor muscles would be a concern for urinary incontinence.

The nurse is caring for a female client who complains of urine leakage when lifting moderate to heavy items at home. Which intervention should the nurse recommend to the​ client?

- pelvic floor exercises Rationale: This client is experiencing urinary incontinence that may be reduced through the strengthening of the pelvic floor muscles with pelvic floor exercises.​ Yoga, abdominal​ exercises, and walking are all good for general health but do not directly help reduce incontinence.

The nurse notices that the urine output of a client is low during the​ 8-hour shift, and the client complains of lower abdominal discomfort. A bladder scan confirms urinary retention. Which collaborative member of the healthcare team should the nurse include to investigate the cause of this urinary​ retention?

- pharmacist ​Rationale: The pharmacist and nurse can collaborate on medication review to determine if medication is contributing to changes in the urinary system. The ostomy nurse would be helpful with wound​ care, and the infection control nurse would assist with infection prevention. Occupational therapy can assist with adaptive techniques for mobility and daily living.

Which nursing intervention would be appropriate for a client with urinary​ retention? (Select all that​ apply.)

- reviewing meds - Using the Credé maneuver - Inserting a urinary catheter ​Rationale: A review of medications for those that may cause urinary retention and use of the Credé maneuver or a urinary catheter all contribute to treatment of urinary retention. Increasing fluid intake would be indicated for a urinary tract infection. Insertion of a vaginal device is indicated for urinary​ incontinence, not urinary retention.

The acute care nurse is caring for a client with urine retention requiring urinary catheterization. Which is the purpose of including the collaborative partner of the infection control nurse in the care of this​ client?

- to prevent infection related to the catheter Rationale: The infection control nurse would assist with infection prevention related to placement and care of the urinary catheter. The ostomy nurse would assist with wound care. The occupational therapist can assist the client with mobility. The radiologist interprets imaging as a diagnostic tool.

The nurse is caring for a client diagnosed with urinary incontinence. Which client statement supports the nursing diagnosis of Social Isolation​? ​(Select all that​ apply.) (NANDA-I​ © 2014)

- ​"When I leave​ home, I worry that I​ can't find a bathroom in​ time." - ​"I am so embarrassed when I wet myself. Even when I use absorbent​ pads, I feel like I smell of​ urine." ​Rationale: Embarrassment and odor and the fear of not being able to find a bathroom in time can lead to social isolation. Seeking out and using absorbent​ products, use of odor​ eliminators, and scheduling diuretics to provide adequate time to make frequent trips to the bathroom are coping strategies that a client may use to continue to participate in normal social activities.