Chapter 66: Care of Patients with Urinary Problems

A nurse cares for a client admitted from a nursing home after several recent falls. What prescription should the nurse complete first? a. Obtain urine sample for culture and sensitivity. b. Administer intravenous antibiotics. c. Encourage protein intake and additional fluids. d. Consult physical therapy for gait training.

ANS: A Although all interventions are or might be important, obtaining a urine sample for urinalysis takes priority. Often urinary tract infection (UTI) symptoms in older adults are atypical, and a UTI may present with new onset of confusion or falling. The urine sample should be obtained before starting antibiotics. Dietary requirements and gait training should be implemented after obtaining the urine sample.

After teaching a client with a history of renal calculi, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I should drink at least 3 liters of fluid every day." b. "I will eliminate all dairy or sources of calcium from my diet." c. "Aspirin and aspirin-containing products can lead to stones." d. "The doctor can give me antibiotics at the first sign of a stone."

ANS: A Dehydration contributes to the precipitation of minerals to form a stone. Although increased intake of calcium causes hypercalcemia and leads to excessive calcium filtered into the urine, if the client is well hydrated the calcium will be excreted without issues. Dehydration increases the risk for supersaturation of calcium in the urine, which contributes to stone formation. The nurse should encourage the client to drink more fluids, not decrease calcium intake. Ingestion of aspirin or aspirin-containing products does not cause a stone. Antibiotics neither prevent nor treat a stone.

A nurse cares for adult clients who experience urge incontinence. For which client should the nurse plan a habit training program? a. A 78-year-old female who is confused b. A 65-year-old male with diabetes mellitus c. A 52-year-old female with kidney failure d. A 47-year-old male with arthritis

ANS: A For a bladder training program to succeed in a client with urge incontinence, the client must be alert, aware, and able to resist the urge to urinate. Habit training will work best for a confused client. This includes going to the bathroom (or being assisted to the bathroom) at set times. The other clients may benefit from another type of bladder training.

After teaching a client who has stress incontinence, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I will limit my total intake of fluids." b. "I must avoid drinking alcoholic beverages." c. "I must avoid drinking caffeinated beverages." d. "I shall try to lose about 10% of my body weight."

ANS: A Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence. Many people try to manage incontinence by limiting fluids. Alcoholic and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.

A nurse obtains the health history of a client with a suspected diagnosis of bladder cancer. Which question should the nurse ask when determining this client's risk factors? a. "Do you smoke cigarettes?" b. "Do you use any alcohol?" c. "Do you use recreational drugs?" d. "Do you take any prescription drugs?"

ANS: A Smoking is known to be a factor that greatly increases the risk of bladder cancer. Alcohol use, recreational drug use, and prescription drug use (except medications that contain phenacetin) are not known to increase the risk of developing bladder cancer.

A nurse teaches a young female client who is prescribed amoxicillin (Amoxil) for a urinary tract infection. Which statement should the nurse include in this client's teaching? a. "Use a second form of birth control while on this medication." b. "You will experience increased menstrual bleeding while on this drug." c. "You may experience an irregular heartbeat while on this drug." d. "Watch for blood in your urine while taking this medication."

ANS: A The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the medication.

A nurse assesses a client who presents with renal calculi. Which question should the nurse ask? a. "Do any of your family members have this problem?" b. "Do you drink any cranberry juice?" c. "Do you urinate after sexual intercourse?" d. "Do you experience burning with urination?"

ANS: A There is a strong association between family history and stone formation and recurrence. Nephrolithiasis is associated with many genetic variations; therefore, the nurse should ask whether other family members have also had renal stones. The other questions do not refer to renal calculi but instead are questions that should be asked of a client with a urinary tract infection.

A nurse teaches a client about self-care after experiencing a urinary calculus treated by lithotripsy. Which statements should the nurse include in this client's discharge teaching? (Select all that apply.) a. "Finish the prescribed antibiotic even if you are feeling better." b. "Drink at least 3 liters of fluid each day." c. "The bruising on your back may take several weeks to resolve." d. "Report any blood present in your urine." e. "It is normal to experience pain and difficulty urinating."

ANS: A, B, C The client should be taught to finish the prescribed antibiotic to ensure that he or she does not get a urinary tract infection. The client should drink at least 3 liters of fluid daily to dilute potential stone-forming crystals, prevent dehydration, and promote urine flow. After lithotripsy, the client should expect bruising that may take several weeks to resolve. The client should also experience blood in the urine for several days. The client should report any pain, fever, chills, or difficulty with urination to the provider as these may signal the beginning of an infection or the formation of another stone.

A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which questions should the nurse ask? (Select all that apply.) a. "How much water do you drink every day?" b. "Do you take estrogen replacement therapy?" c. "Does anyone in your family have a history of cystitis?" d. "Are you on steroids or other immune-suppressing drugs?" e. "Do you drink grapefruit juice or orange juice daily?"

ANS: A, B, D Fluid intake, estrogen levels, and immune suppression all can increase the chance of recurrent cystitis. Family history is usually insignificant, and cranberry juice, not grapefruit or orange juice, has been found to increase the acidic pH and reduce the risk for bacterial cystitis.

A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their clinical manifestation? (Select all that apply.) a. Stress incontinence - Urine loss with physical exertion b. Urge incontinence - Large amount of urine with each occurrence c. Functional incontinence - Urine loss results from abnormal detrusor contractions d. Overflow incontinence - Constant dribbling of urine e. Reflex incontinence - Leakage of urine without lower urinary tract disorder

ANS: A, B, D Stress incontinence is a loss of urine with physical exertion, coughing, sneezing, or exercising. Urge incontinence presents with an abrupt and strong urge to void and usually has a large amount of urine released with each occurrence. Overflow incontinence occurs with bladder distention and results in a constant dribbling of urine. Functional incontinence is the leakage of urine caused by factors other than a disorder of the lower urinary tract. Reflex incontinence results from abnormal detrusor contractions from a neurologic abnormality.

A nurse teaches a client with a history of calcium phosphate urinary stones. Which statements should the nurse include in this client's dietary teaching? (Select all that apply.) a. "Limit your intake of food high in animal protein." b. "Read food labels to help minimize your sodium intake." c. "Avoid spinach, black tea, and rhubarb." d. "Drink white wine or beer instead of red wine." e. "Reduce your intake of milk and other dairy products."

ANS: A, B, E Clients with calcium phosphate urinary stones should be taught to limit the intake of foods high in animal protein, sodium, and calcium. Clients with calcium oxalate stones should avoid spinach, black tea, and rhubarb. Clients with uric acid stones should avoid red wine.

A nurse teaches a female client who has stress incontinence. Which statements should the nurse include about pelvic muscle exercises? (Select all that apply.) a. "When you start and stop your urine stream, you are using your pelvic muscles." b. "Tighten your pelvic muscles for a slow count of 10 and then relax for a slow count of 10." c. "Pelvic muscle exercises should only be performed sitting upright with your feet on the floor." d. "After you have been doing these exercises for a couple days, your control of urine will improve." e. "Like any other muscle in your body, you can make your pelvic muscles stronger by contracting them."

ANS: A, B, E The client should be taught that the muscles used to start and stop urination are pelvic muscles, and that pelvic muscles can be strengthened by contracting and relaxing them. The client should tighten pelvic muscles for a slow count of 10 and then relax the muscles for a slow count of 10, and perform this exercise 15 times while in lying-down, sitting-up, and standing positions. The client should begin to notice improvement in control of urine after several weeks of exercising the pelvic muscles.

A nurse teaches a client about self-catheterization in the home setting. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Wash your hands before and after self-catheterization." b. "Use a large-lumen catheter for each catheterization." c. "Use lubricant on the tip of the catheter before insertion." d. "Self-catheterize at least twice a day or every 12 hours." e. "Use sterile gloves and sterile technique for the procedure." f. "Maintain a specific schedule for catheterization."

ANS: A, C, F The key points in self-catheterization include washing hands, using lubricants, and maintaining a regular schedule to avoid distention and retention of urine that leads to bacterial growth. A smaller rather than a larger lumen catheter is preferred. The client needs to catheterize more often than every 12 hours. Self-catheterization in the home is a clean procedure.

A nurse reviews the laboratory findings of a client with a urinary tract infection. The laboratory report notes a "shift to the left" in a client's white blood cell count. Which action should the nurse take? a. Request that the laboratory perform a differential analysis on the white blood cells. b. Notify the provider and start an intravenous line for parenteral antibiotics. c. Collaborate with the unlicensed assistive personnel (UAP) to strain the client's urine for renal calculi. d. Assess the client for a potential allergic reaction and anaphylactic shock.

ANS: B An increase in band cells creates a "shift to the left." A left shift most commonly occurs with urosepsis and is seen rarely with uncomplicated urinary tract infections. The nurse will be administering antibiotics, most likely via IV, so he or she should notify the provider and prepare to give the antibiotics. The shift to the left is part of a differential white blood cell count. The nurse would not need to strain urine for stones. Allergic reactions are associated with elevated eosinophil cells, not band cells.

A nurse plans care for clients with urinary incontinence. Which client is correctly paired with the appropriate intervention? a. A 29-year-old client after a difficult vaginal delivery - Habit training b. A 58-year-old postmenopausal client who is not taking estrogen therapy - Electrical stimulation c. A 64-year-old female with Alzheimer's-type senile dementia - Bladder training d. A 77-year-old female who has difficulty ambulating - Exercise therapy

ANS: B Exercise therapy and electrical stimulation are used for clients with stress incontinence related to childbirth or low levels of estrogen after menopause. Exercise therapy increases pelvic wall strength; it does not improve ambulation. Physical therapy and a bedside commode would be appropriate interventions for the client who has difficulty ambulating. Habit training is the type of bladder training that will be most effective with cognitively impaired clients. Bladder training can be used only with a client who is alert, aware, and able to resist the urge to urinate.

After delegating care to an unlicensed assistive personnel (UAP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the UAP's understanding. Which action indicates the UAP needs additional teaching? a. Toileting the client after breakfast b. Changing the client's incontinence brief when wet c. Encouraging the client to drink fluids d. Recording the client's incontinence episodes

ANS: B Habit training is undermined by the use of absorbent incontinence briefs or pads. The nurse should re-educate the UAP on the technique of habit training. The UAP should continue to toilet the client after meals, encourage the client to drink fluids, and record incontinent episodes.

A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, "I never have urinary tract infections. Why is this happening now?" How should the nurse respond? a. "Your immune system becomes less effective as you age." b. "Low estrogen levels can make the tissue more susceptible to infection." c. "You should be more careful with your personal hygiene in this area." d. "It is likely that you have an untreated sexually transmitted disease."

ANS: B Low estrogen levels decrease moisture and secretions in the perineal area and cause other tissue changes, predisposing it to the development of infection. Urethritis is most common in postmenopausal women for this reason. Although immune function does decrease with aging and sexually transmitted diseases are a known cause of urethritis, the most likely reason in this client is low estrogen levels. Personal hygiene usually does not contribute to this disease process.

An emergency department nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question should the nurse ask first? a. "Are you drinking plenty of water?" b. "What medications are you taking?" c. "Have you tried laxatives or enemas?" d. "Has this type of thing ever happened before?"

ANS: B Some types of incontinence are treated with anticholinergic medications such as propantheline (Pro-Banthine). Anticholinergic side effects include dry mouth, constipation, and urinary retention. The nurse needs to assess the client's medication list to determine whether the client is taking an anticholinergic medication. If he or she is taking anticholinergics, the nurse should further assess the client's manifestations to determine if they are related to a simple side effect or an overdose. The other questions are not as helpful to understanding the current situation.

A nurse teaches a client who is starting urinary bladder training. Which statement should the nurse include in this client's teaching? a. "Use the toilet when you first feel the urge, rather than at specific intervals." b. "Try to consciously hold your urine until the scheduled toileting time." c. "Initially try to use the toilet at least every half hour for the first 24 hours." d. "The toileting interval can be increased once you have been continent for a week."

ANS: B The client should try to hold the urine consciously until the next scheduled toileting time. Toileting should occur at specific intervals during the training. The toileting interval should be no less than every hour. The interval can be increased once the client becomes comfortable with the interval.

A nurse assesses a male client who is recovering from a urologic procedure. Which assessment finding indicates an obstruction of urine flow? a. Severe pain b. Overflow incontinence c. Hypotension d. Blood-tinged urine

ANS: B The most common manifestation of urethral stricture after a urologic procedure is obstruction of urine flow. This rarely causes pain and has no impact on blood pressure. The client may experience overflow incontinence with the involuntary loss of urine when the bladder is distended. Blood in the urine is not a manifestation of the obstruction of urine flow.

A nurse assesses a client who is recovering from extracorporeal shock wave lithotripsy for renal calculi. The nurse notes an ecchymotic area on the client's right lower back. Which action should the nurse take? a. Administer fresh-frozen plasma. b. Apply an ice pack to the site. c. Place the client in the prone position. d. Obtain serum coagulation test results.

ANS: B The shock waves from lithotripsy can cause bleeding into the tissues through which the waves pass. Application of ice can reduce the extent and discomfort of the bruising. Although coagulation test results and fresh-frozen plasma are used to assess and treat bleeding disorders, ecchymosis after this procedure is not unusual and does not warrant a higher level of intervention. Changing the client's position will not decrease bleeding.

A nurse assesses a client with a fungal urinary tract infection (UTI). Which assessments should the nurse complete? (Select all that apply.) a. Palpate the kidneys and bladder. b. Assess the medical history and current medical problems. c. Perform a bladder scan to assess post-void residual. d. Inquire about recent travel to foreign countries. e. Obtain a current list of medications.

ANS: B, E Clients who are severely immunocompromised or who have diabetes mellitus are more prone to fungal UTIs. The nurse should assess for these factors by asking about medical history, current medical problems, and the current medication list. A physical examination and a post-void residual may be needed, but not until further information is obtained indicating that these examinations are necessary. Travel to foreign countries probably would not be important because, even if exposed, the client needs some degree of compromised immunity to develop a fungal UTI.

A nurse teaches clients about the difference between urge incontinence and stress incontinence. Which statements should the nurse include in this education? (Select all that apply.) a. "Urge incontinence involves a post-void residual volume less than 50 mL." b. "Stress incontinence occurs due to weak pelvic floor muscles." c. "Stress incontinence usually occurs in people with dementia." d. "Urge incontinence can be managed by increasing fluid intake." e. "Urge incontinence occurs due to abnormal bladder contractions."

ANS: B, E Clients who suffer from stress incontinence have weak pelvic floor muscles or urethral sphincter and cannot tighten their urethra sufficiently to overcome the increased detrusor pressure. Stress incontinence is common after childbirth, when the pelvic muscles are stretched and weakened from pregnancy and delivery. Urge incontinence occurs in people who cannot suppress the contraction signal from the detrusor muscle. Abnormal detrusor contractions may be a result of neurologic abnormalities including dementia, or may occur with no known abnormality. Post-void residual is associated with reflex incontinence, not with urge incontinence or stress incontinence. Management of urge incontinence includes decreasing fluid intake, especially in the evening hours.

A nurse assesses a client with bladder cancer who is recovering from a complete cystectomy with ileal conduit. Which assessment finding should alert the nurse to urgently contact the health care provider? a. The ileostomy is draining blood-tinged urine. b. There is serous sanguineous drainage present on the surgical dressing. c. The ileostomy stoma is pale and cyanotic in appearance. d. Oxygen saturations are 92% on room air.

ANS: C A pale or cyanotic stoma indicates impaired circulation to the stoma and must be treated to prevent necrosis. Blood-tinged urine and serous sanguineous drainage are expected after this type of surgery. Oxygen saturation of 92% on room air is at the low limit of normal.

A confused client with pneumonia is admitted with an indwelling catheter in place. During interdisciplinary rounds the following day, which question should the nurse ask the primary health care provider? a. "Do you want daily weights on this client?" b. "Will the client be able to return home?" c. "Can we discontinue the indwelling catheter?" d. "Should we get another chest x-ray today?"

ANS: C An indwelling catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse should inquire about removing the catheter. All other questions might be appropriate, but because of client safety, this question takes priority.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of bacterial cystitis? a. A 36-year-old female who has never been pregnant b. A 42-year-old male who is prescribed cyclophosphamide c. A 58-year-old female who is not taking estrogen replacement d. A 77-year-old male with mild congestive heart failure

ANS: C Females at any age are more susceptible to cystitis than men because of the shorter urethra in women. Postmenopausal women who are not on hormone replacement therapy are at increased risk for bacterial cystitis because of changes in the cells of the urethra and vagina. The middle-aged woman who has never been pregnant would not have a risk potential as high as the older woman who is not using hormone replacement therapy.

After teaching a client with bacterial cystitis who is prescribed phenazopyridine (Pyridium), the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I will not take this drug with food or milk." b. "If I think I am pregnant, I will stop the drug." c. "An orange color in my urine should not alarm me." d. "I will drink two glasses of cranberry juice daily."

ANS: C Phenazopyridine discolors urine, most commonly to a deep reddish orange. Many clients think they have blood in their urine when they see this. In addition, the urine can permanently stain clothing. Phenazopyridine is safe to take if the client is pregnant. There are no dietary restrictions or needs while taking this medication.

A nurse provides phone triage to a pregnant client. The client states, "I am experiencing a burning pain when I urinate." How should the nurse respond? a. "This means labor will start soon. Prepare to go to the hospital." b. "You probably have a urinary tract infection. Drink more cranberry juice." c. "Make an appointment with your provider to have your infection treated." d. "Your pelvic wall is weakening. Pelvic muscle exercises should help."

ANS: C Pregnant clients with a urinary tract infection require prompt and aggressive treatment because cystitis can lead to acute pyelonephritis during pregnancy. The nurse should encourage the client to make an appointment and have the infection treated. Burning pain when urinating does not indicate the start of labor or weakening of pelvic muscles.

A nurse cares for a client with urinary incontinence. The client states, "I am so embarrassed. My bladder leaks like a young child's bladder." How should the nurse respond? a. "I understand how you feel. I would be mortified." b. "Incontinence pads will minimize leaks in public." c. "I can teach you strategies to help control your incontinence." d. "More women experience incontinence than you might think."

ANS: C The nurse should accept and acknowledge the client's concerns, and assist the client to learn techniques that will allow control of urinary incontinence. The nurse should not diminish the client's concerns with the use of pads or stating statistics about the occurrence of incontinence.

A nurse teaches a client with functional urinary incontinence. Which statement should the nurse include in this client's teaching? a. "You must clean around your catheter daily with soap and water." b. "Wash the vaginal weights with a 10% bleach solution after each use." c. "Operations to repair your bladder are available, and you can consider these." d. "Buy slacks with elastic waistbands that are easy to pull down."

ANS: D Functional urinary incontinence occurs as the result of problems not related to the client's bladder, such as trouble ambulating or difficulty accessing the toilet. One goal is that the client will be able to manage his or her clothing independently. Elastic waistband slacks that are easy to pull down can help the client get on the toilet in time to void. The other instructions do not relate to functional urinary incontinence.

A nurse plans care for a client with overflow incontinence. Which intervention should the nurse include in this client's plan of care to assist with elimination? a. Stroke the medial aspect of the thigh. b. Use intermittent catheterization. c. Provide digital anal stimulation. d. Use the Valsalva maneuver.

ANS: D In clients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressure, such as that achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate), can initiate voiding. Stroking the medial aspect of the thigh or providing digital anal stimulation requires the reflex arc to be intact to initiate elimination. Due to the high risk for infection, intermittent catheterization should only be implemented when other interventions are not successful.

A nurse cares for a client who has kidney stones from secondary hyperoxaluria. Which medication should the nurse anticipate administering? a. Phenazopyridine (Pyridium) b. Propantheline (Pro-Banthine) c. Tolterodine (Detrol LA) d. Allopurinol (Zyloprim)

ANS: D Stones caused by secondary hyperoxaluria respond to allopurinol (Zyloprim). Phenazopyridine is given to clients with urinary tract infections. Propantheline is an anticholinergic. Tolterodine is an anticholinergic with smooth muscle relaxant properties.

A nurse cares for a client who is scheduled for the surgical creation of an ileal conduit. The client states, "I am anxious about having an ileal conduit. What is it like to have this drainage tube?" How should the nurse respond? a. "I will ask the provider to prescribe you an antianxiety medication." b. "Would you like to discuss the procedure with your doctor once more?" c. "I think it would be nice to not have to worry about finding a bathroom." d. "Would you like to speak with someone who has an ileal conduit?"

ANS: D The goal for the client who is scheduled to undergo a procedure such as an ileal conduit is to have a positive self-image and a positive attitude about his or her body. Discussing the procedure candidly with someone who has undergone the same procedure will foster such feelings, especially when the current client has an opportunity to ask questions and voice concerns to someone with first-hand knowledge. Medications for anxiety will not promote a positive self-image and a positive attitude, nor will discussing the procedure once more with the physician or hearing the nurse's opinion.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for bladder cancer? a. A 25-year-old female with a history of sexually transmitted diseases b. A 42-year-old male who has worked in a lumber yard for 10 years c. A 55-year-old female who has had numerous episodes of bacterial cystitis d. An 86-year-old male with a 50-pack-year cigarette smoking history

ANS: D The greatest risk factor for bladder cancer is a long history of tobacco use. The other factors would not necessarily contribute to the development of this specific type of cancer.