Pearson Elimination

The nurse is providing discharge teaching to a patient diagnosed with urinary incontinence. Which patient statement indicates the need for further teaching regarding preventive methods for urinary incontinence? A. "I have switched to a low-fiber diet." B. "I have begun a smoking-cessation program." C. "I drink six to eight 8-ounce glasses of water each day." D. "I have decreased the amount of coffee I drink each day from eight cups to two."

Answer: A A low-fiber diet is not indicated as a preventive method of decreasing urinary incontinence. The other patient statements indicate understanding of the teaching session.

How much fluid per day should be ingested by a patient experiencing constipation? A. 2500 mL B. 1500 mL C. 2000 mL D. 1000 mL

Answer: A A patient who is experiencing constipation should drink at least 2500 mL of fluid per day, as tolerated. Constipation can cause other problems for some patients. Straining associated with constipation is often combined with taking in a deep breath and holding it. This combination can present problems for individuals with heart disease, brain injuries, or respiratory disease. When a deep breath is taken and held while straining to have a bowel movement, physiological changes occur in the body.

The nurse is providing dietary teaching to a patient with chronic constipation. Which food selection by the patient indicates that the instructions were understood? A. Split pea soup B. Creamed wheat cereal with low-fat milk C. Chocolate pudding D. White bread and butter

Answer: A A patient with chronic constipation should be encouraged to increase their fiber and fluid intake. Split pea soup is high in fiber. White bread, creamed wheat cereal, and chocolate pudding are all low-fiber foods and indicate that the patient did not understand the instructions.

A patient has been having multiple episodes of fecal incontinence. Which diagnostic test should the nurse anticipate to evaluate anal sphincter function? A. Anorectal manometry B. Barium enema C. Colonoscopy D. Upper GI

Answer: A An anorectal manometry procedure is used to evaluate anal sphincter muscle function. In this test, a small, flexible balloon catheter is introduced into the rectum, and pressure is measured in the rectum and internal and external sphincters. A colonoscopy is often used to visualize the colon and rectum to screen for polyps, cysts, tumors, lesions, diverticula, inflammation, bleeding, and the general integrity of the mucosal lining. Tissue samples can be obtained for biopsy during a colonoscopy. X-ray imaging, including barium enema x-ray and defecography, can be performed to visualize the colon and part of the small intestine to determine how efficiently feces is evacuated. An upper GI is an endoscopy to visualize the esophagus and stomach.

An 82-year-old female patient is admitted to a long-term care facility because the family found it too difficult to perform care in the home to meet toileting needs. Which nursing action is appropriate when providing care for the patient? A. Assessing the patient for physical and mental abilities and limitations, usual voiding pattern, and ability to assist with toileting B. Reviewing the patient's daily medications and holding those that cause diuresis C. Limiting the patient's fluid intake to less than 1.5 L per day to reduce the number of times she will need to void D. Performing intermittent catheterization on a schedule to keep the patient's clothing and skin dry

Answer: A Assessing the patient for physical and mental abilities, usual voiding pattern, and ability to assist with toileting will assist in planning their care. Holding medications that cause diuresis may cause the patient to develop additional health problems with the renal or cardiovascular systems. Performing intermittent catheterization on a routine basis increases the chance for infection. Reducing fluid intake to less than 1.5 L can cause irritation of the bladder due to urine concentration and increase incontinence.

The nurse is caring for a patient with urinary incontinence who has been prescribed bladder-training behavior modification. Which goal of therapy should the nurse include in the teaching session with the patient? A. To gradually increase the bladder capacity by increasing the intervals between voiding and resisting the urge to void between scheduled times B. To toilet at regular intervals (e.g., every 2-4 hours) C. To improve pelvic floor muscle strength by stopping the urine flow during voiding and holding for a few seconds D. To toilet on a schedule that corresponds with the normal pattern

Answer: A Bladder training increases the bladder capacity by increasing the intervals between voiding and resisting the urge to void between scheduled times. Habit training is toileting on a schedule that corresponds with the normal pattern. Scheduled voiding is toileting at regular intervals. Kegel exercise is a technique that is done to strengthen the pelvic floor muscles.

The nurse is caring for a pregnant patient who reports feeling constipated and burning upon urination. Which condition should the nurse suspect as the cause? A. Urinary tract infection B. Sexually transmitted infection C. Bladder infection D. Hormonal shift from the pregnancy

Answer: A Constipation may also predispose children, older adults, and pregnant women for developing a UTI. Pressure placed on the bladder, ureters, or urethra by the colon when it contains a large amount of hard stool may cause structures of the urinary tract to develop a partial obstruction. When urine is allowed to pool in one area for an extended amount of time, bacteria can grow and cause infection. The symptoms of a bladder infection would consist of a lingering urge to urinate, frequency at bedtime, and blood-tinged urine. A hormonal shift during pregnancy would not cause burning upon urination, but a loosening of ligaments and joints throughout the body. Sexually transmitted infections present themselves in many forms. Some common symptoms would be the presence of warts, genital pain, or fever.

The nurse is teaching a patient measures to facilitate defecation. Which suggestion should the nurse include? A. "Drink a glass of warm water before breakfast." B. "Eat a pureed diet." C. "Take a laxative if a bowel movement does not occur daily." D. "Consume up to 1000 mL of fluid per day."

Answer: A Drinking a warm glass of water can stimulate peristalsis and facilitate defecation after food is eaten. Taking laxatives frequently is contraindicated because it can make a patient dependent on them. Taking excessive amounts of laxatives lessens the possibility of the patient returning to a normal pattern of defecation. Increasing water consumption is important to relieve constipation and promote defecation. However, the patient should consume about 2500 mL, not 1000 mL, of fluid. A pureed diet does not provide adequate dietary fiber. Increasing dietary fiber will help promote defecation. It is not necessary to have a daily bowel movement. Eating high-fiber foods promotes peristalsis and bowel movements.

A male patient is experiencing urinary issues and the healthcare provider has ordered a digital rectal exam. The patient asks the nurse what to expect from the test. How should the nurse reply? A. "The physician will insert a single gloved and lubricated finger into the rectum to feel the prostate gland." B. "The physician will insert a small needle into the prostate through the rectum in order to take a small sample for biopsy." C. "The physician will insert a small ultrasound probe into the rectum in order to look at the prostate gland." D. "The physician will insert two gloved and lubricated fingers into the rectum in order to feel the rectum, prostate, and bladder."

Answer: A During a digital rectal examination (DRE), the physician will insert a single gloved and lubricated finger into the rectum in order to palpate, or feel, the prostate gland. An ultrasound probe is not used during a DRE. Only the prostate gland is felt, not the bladder. A needle biopsy is not part of a DRE.

Which assessment finding should the nurse note in a patient diagnosed with urinary incontinence? A. Bladder bulging B. Use of alternative therapies C. Hypoactive bowel sounds D. Enlarged prostate

Answer: A During the physical examination for a patient experiencing urinary incontinence, the nurse may find perineal redness, physical or cognitive limitations, and bladder bulging. The use of alternative therapies is assessed during the patient's health history. Bowel sounds are not assessed during a focused urinary assessment. An enlarged prostate tends to cause problems with urinary retention, not incontinence.

The nurse is caring for a bedbound female patient. Which intervention should the nurse implement to support voiding and avoid urine retention in the female patient? A. Elevating the head of the bed B. Providing a urinal C. Cooling the bedpan D. Remaining at the bedside during voiding

Answer: A Elevating the head of the bed allows the patient to sit in a more natural position. A urinal would be provided to the male patient. Providing privacy for the patient and warming the bedpan help to promote voiding.

The nurse is caring for a patient who performs self-catheterization for urinary retention. Which assessment finding indicates a potential complication related to the care of this patient? A. Fever B. Complete emptying of bladder C. Increased intake of caffeine D. Intake of 3 L of fluids per day

Answer: A Fever is an indication that there may be a urinary tract infection from urinary catheterization. Fluid intake of 2.5 to 3 L per day promotes normal urine production and voiding. Self-catheterization should result in complete bladder emptying. Caffeine intake may lead to bladder irritation but is not a complication of self-catheterization.

Which collaborative therapy should the nurse expect to be utilized in the management of a fecal impaction? A. Digital removal of the impaction B. Intake of cold drinks, especially before the usual time of defecation C. Saline enemas D. Intake of high-residue foods with decreased fluids

Answer: A For patients with fecal impactions, bowel training programs may be helpful. Digital removal of the impaction can be accomplished with administration of an oil retention enema (not saline) 30 minutes before the disimpaction, followed by cleansing enemas as indicated. The intake of hot, not cold, drinks just before defecation is helpful. High-residue foods will increase bulk in the colon. High-fiber foods should be consumed. High-residue foods and decreased fluid intake will increase the amount of stool in the colon.

The nurse should identify which risk factor as contributing to bowel incontinence? A. Damage to a nerve B. Ingestion of a high-residue diet C. Overeating at night D. Performing Kegel exercises

Answer: A Individuals with nerve damage, including multiple sclerosis and spinal cord injury, are at risk of bowel incontinence. Such recommended dietary measures as consuming a high-fiber diet and ample fluids to maintain a soft-formed stool, or maintaining a low-residue diet to reduce the number of stools, may be beneficial. Kegel exercises to improve sphincter and pelvic floor muscle tone may be of long-term benefit.

Which condition should the nurse recognize as a cause of fecal incontinence? A. Anorectal injury B. Irregular defecation habits C. Irritable bowel syndrome D. Gastrointestinal reflux disease

Answer: A Irritable bowel syndrome may cause diarrhea, but not necessarily incontinence. If the external anal sphincter is paralyzed by injury or disease (anorectal injury), defecation occurs automatically when the internal sphincter relaxes. Irregular defecation habits increase the patient's risk for constipation, not fecal incontinence. Gastrointestinal reflux disease is the regurgitation of stomach acids back into the esophagus. It does not cause fecal incontinence.

A patient reports urine leakage. The nurse notes the following medical history: obesity, ambulation difficulty, smoking, and hypertension treated with diuretics. Which lifestyle intervention should the nurse suggest to the patient to reduce urinary incontinence? A. Reducing physical barriers to toileting B. Decreasing activity C. Stopping all diuretics D. Switching from cigarette smoking to chewing tobacco

Answer: A Reducing physical barriers to toileting promotes a safe path to the bathroom for use of the toilet. Regular exercise supports weight loss. Tobacco cessation would be indicated. A medication review helps to identify contributing factors, but stopping medications would not be instructed without healthcare provider input.

A patient is admitted to a clinic with urinary retention caused by a mechanical obstruction. The nurse should suspect which condition as the likely cause of the patient's condition? A. Repeated urinary tract infections B. Benign prostatic hyperplasia C. Anticholinergic medications D. Fecal impaction

Answer: A Repeated urinary tract infections lead to scarring of structure, which is a functional problem associated with urinary retention. Either mechanical obstruction of the bladder outlet or a functional problem can cause urinary retention. Scarring caused by repeated UTIs subsequently leads to urethral stricture and produces mechanical obstruction. Benign prostatic hypertrophy and fecal impaction are the causes of an obstruction that will lead to urinary retention. Anticholinergic medications may cause retention, but this is not a functional problem. Once the medication is stopped, the urinary retention resolves.

The nurse is caring for several patients at the gastrointestinal clinic. Which patient should the nurse anticipate to be a candidate for surgical repair? A. The patient with loss of sphincter control B. The patient with chronic constipation C. The patient with acute and severe diarrhea D. The patient with stool impaction

Answer: A Severe bowel incontinence due to loss of sphincter control can be repaired surgically if other measures have not worked. Chronic constipation can be treated with medications, enemas, or diet changes but not surgery. Stool impaction may require manual removal with changes in fluid and fiber intake. Surgery is not an option for fecal impaction. Severe or acute diarrhea cannot be treated surgically.

A patient presents with abdominal pain, history of chronic constipation, and possible fecal impaction. Which diagnostic test should the nurse anticipate will be ordered? A. Digital rectal examination (DRE) B. Chest x-ray C. Abdominal ultrasound D. Upper endoscopy

Answer: A The nurse should anticipate that a digital rectal examination will be done to determine whether the patient is impacted. An upper endoscopy, abdominal ultrasound, or chest x-ray will not assist in determining whether the patient is experiencing fecal impaction.

Which health promotion instruction should the nurse give a patient regarding constipation? A. "Monitor bowel habits." B. "Limit exercise." C. "Increase potassium intake." D. "Follow a low-fiber diet."

Answer: A The patient should be taught to monitor bowel habits to see whether certain foods or activities aggravate or alleviate the symptoms of constipation. Exercise increases bowel motility and should be encouraged as a health promotion activity. The nurse should encourage the patient to drink plenty of fluids, up to 2500 mL per day, as indicated, to help keep the bowel movements soft. The nurse should encourage the patient to consume a high-fiber diet to promote bowel motility and help keep the bowel soft. Potassium intake should be monitored in the patient with diarrhea, not constipation.

The nurse is assigned to care for four patients today. Which patient is at highest risk for developing acute urinary retention? A. A 28-year-old female one day postpartum B. A 20-year-old female with infertility C. A 60-year-old female with mastitis D. A 50-year-old female with ovarian cancer

Answer: A The patient who is one day postpartum is at highest risk for urinary retention, secondary to inflammation in the perineal area after delivery. The patients with infertility, ovarian cancer, and mastitis do not have any risk factors for urinary retention.

A patient diagnosed with bowel obstruction is scheduled for surgical resection of the bowel. Which nursing action is most appropriate for this patient? A. Preparing needed preoperative instructions B. Preparing instruction on care and cleaning of the ostomy pouch C. Preparing information on chemotherapy and/or radiation therapy D. Preparing for the administration of an enema

Answer: A The patient who needs surgical resection of the bowel will need preoperative instructions, and it is the nurse's role to provide them. Enemas are used for impactions, not obstructions. Chemotherapy and radiation therapy are used for bowel cancer. Instruction on care and cleaning of the ostomy pouch will depend on whether the resection requires one.

The nurse is preparing a presentation on urinary elimination problems for a group of older adults. Which important fact should the nurse include? A. Urinary retention is uncommon in women. B. Very few men experience urinary incontinence after treatment for enlarged prostate. C. A majority of men report moderate to severe lower urinary tract symptoms. D. Very few women complain of urinary incontinence.

Answer: A Urinary retention is quite uncommon among women, unless there is a physiological basis, such as a neurogenic bladder. Up to 60% of men over the age of 60 report having issues with urinary incontinence, usually associated with treatment for an enlarged prostate. Only about 7% of young, healthy men without a history of prostate problems report lower urinary tract symptoms. Around 94.3% of women reported incontinence or lower urinary tract symptoms.

A patient with urinary incontinence is scheduled for urodynamic testing. The patient's family asks the nurse, "What is this test for?" Which response by the nurse is accurate? A. "This test will measure bladder strength and urinary sphincter health." B. "This test will evaluate detrusor muscle function." C. "This test will identify structural disorders contributing to incontinence." D. "This test will determine how completely the bladder empties with voiding."

Answer: A Urodynamic testing measures bladder strength and urinary sphincter health. Cystometrography is a diagnostic test done to evaluate detrusor muscle function. A cystoscopy identifies structural disorders contributing to incontinence. Postvoiding residual volume determines how completely the bladder empties with voiding.

The labor and delivery nurse is caring for the postpartum mother. Which risk factor places the pregnant and postpartum female at an increased risk for urinary retention? A. Use of analgesia B. Low birth weight C. Short course of anesthesia D. Vaginal delivery

Answer: A Use of analgesia with childbirth is a risk factor for urinary retention. A cesarean, not vaginal, delivery, places the mother at higher risk as well as higher birth weight, and a longer operative time with anesthesia.

The nurse is assessing a client who is experiencing lower abdominal pain. Which abnormal finding requires the nurse to evaluate​ further? A. Palpable bladder after urination B. Absence of bruits over the renal arteries C. Midline urinary meatus D. Absence of tenderness on kidney palpation

Answer: A ​Rationale: Normally, the bladder​ isn't palpable over the pubic​ bone, especially if the client has just urinated. Absence of bruits over the renal arteries is a normal finding on auscultation. The meatus should be midline and without redness or excoriation. There should be no tenderness or pain on palpation or percussion of the kidneys.

During an office​ visit, a client reports infrequent and difficult bowel movements. Which teaching topic should the nurse include when developing the​ client's plan of​ care? (Select all that​ apply.) A. The importance of staying active B. The use of laxatives or stool softeners C. The importance of cooking and storing food correctly D. The importance of consuming adequate amounts of fluid and fiber E. The avoidance of raw​ fruit, vegetables, and meat when traveling abroad

Answer: A, B, D ​Rationale: Being active and consuming adequate fluids and fiber in the diet can prevent constipation. Clients at high risk of constipation may prevent it by taking daily laxatives or stool softeners. Cooking and storing food properly and avoiding raw foods during travel would address​ diarrhea, not constipation.

The nurse is caring for a child with constipation. Which statement by the nurse reflects an understanding of dietary changes that should be suggested to the child's parents? A. "The parents should limit the amount of grains consumed in the diet." B. "The parents should remove cow's milk from the diet temporarily." C. "The parents should remove fruit juices from the diet temporarily." D. "The parents should remove all fruit from the diet temporarily."

Answer: B A balanced diet that includes grains, fruits, and vegetables is recommended as part of the treatment of constipation in children. Fruit juice does not take the place of fruit, although prune, pear, and apple juices can cause increased motility and water content in stools. Cow's milk in excess may cause constipation; children without lactose intolerance usually tolerate milk without issue. A limited temporary trial of removing cow's milk may be tried if other measures to correct constipation fail.

The nurse is evaluating a patient with new onset of fecal incontinence. Which collaborative activity should the nurse anticipate to evaluate the patient's sphincter tone? A. Colonoscopy B. Digital rectal exam C. Cystoscopy D. Retrograde pyelography

Answer: B A digital rectal exam provides information about anorectal sphincter tone. A colonoscopy evaluates the intestines for growths, masses, polyps, lesions, bleeding, or diverticula. Retrograde pyelography and cystoscopy are diagnostic procedures to evaluate urinary system disorders, not bowel incontinence.

The nurse is discussing nonpharmacological treatments with the patient who has urinary incontinence. Which information in the patient's history would indicate that the use of a pessary could benefit this patient? A. Functional incontinence B. History of multiparity C. Spinal cord injury D. Benign prostatic hypertrophy

Answer: B A pessary is a stiff ring that is inserted into the vagina to hold up the uterus or bladder and rectum. It is a firm ring that presses against the wall of the vagina and urethra to help decrease urine leakage. It is used in patients with a history of uterine prolapse, such as a women who have given birth to many children (multiparity). The treatment for functional incontinence is timed voiding. This would be used in a patient with mobility issues or dementia. Benign prostatic hypertrophy is treated with surgery to remove excess prostate tissue. Incontinence related to spinal cord injuries involves catheterization and/or medications.

The nurse taught a 65-year-old patient about interventions to prevent constipation. Which patient statement demonstrates that the teaching was effective? A. "I should not eat after 7 p.m." B. "I should drink more fluids throughout the day." C. "I should avoid fruits high in sugar." D. "I should continue to take a laxative for the next month."

Answer: B Although fecal transit in the large intestine slows with aging, the increased incidence of constipation in older adults is thought to relate more to impaired general health status, increased medication use, and decreased physical activity. Factors contributing to increased risk for constipation include lack of teeth or ill-fitting, broken, or lost dentures; periodontal disease; and lack of fresh produce or other sources of bulk or fiber. The older adult may self-limit daily fluid intake, especially water, to decrease frequency of urination, or episodes of incontinence, unintentionally increasing the potential for constipation. Dietary changes such as eating late at night and avoiding fruits high in sugar are not common culprits of constipation. Direction may be given to limit these factors based on acid reflux disease or diabetes. The use of NSAIDs on a regular basis can have a constipating effect, so this would be contraindicated in a patient who is prone to constipation.

The nurse is caring for a patient with major fecal incontinence. Which collaborative intervention should the nurse be prepared to implement? A. Administer a suppository. B. Administer an antibiotic. C. Suggest behavior modification. D. Conduct digital stimulation.

Answer: B An antimicrobial agent may be prescribed for major fecal incontinence because it may be caused by infection. Also, the nurse should expect that an antidiarrheal agent will also be prescribed. The cause of this condition is not behavioral. Digital stimulation and administering a suppository would be implemented for constipation.

A 60-year-old patient presents with multiple episodes of fecal incontinence over the past week. Which condition should the nurse consider related to decreased muscle tone and rectal sensation? A. Limited mobility B. Constipation C. Dehydration D. Excessive eating

Answer: B Attributes related to structural integrity of the intestinal tract can include decreasing muscle tone and rectal sensation from cumulative local trauma resulting from childbirth, constipation, rectal impaction, or other conditions that can affect the structures of the intestinal tract. Older adults are at increased risk for fecal incontinence due to chronic disease, polypharmacy, and fecal impaction from inactivity or immobility and reduced fluid intake.

Which intervention would be most appropriate for the nurse to include in the plan of care for a child with nocturnal enuresis? A. Use absorbent bed pads to prevent skin excoriation. B. Wake the child up during the night to use the bathroom. C. Administer medications for overactive bladder. D. Recommend counseling for the child to determine the cause.

Answer: B Children with nocturnal enuresis frequently sleep soundly and have difficulty waking up at night to use the bathroom. Therefore, the nurse would wake the child up at night to urinate to prevent incontinent episodes. While bed pads may help prevent skin excoriation, it does not address the cause of the incontinence. Counseling may not be appropriate if the cause is physiological. Medications for overactive bladder are used but would not be first-line treatment for nocturnal enuresis.

The nurse notes the need for scheduled toileting on a patient's plan of care. For which patient is the nurse caring? A. Patient with renal failure B. Patient with dementia who has developed functional incontinence C. Patient with a urinary tract infection D. Patient with renal calculi

Answer: B Dementia is a risk factor for urinary incontinence because the patient may not have the cognitive ability to reach the bathroom in time. Therefore, scheduled toileting would be the least invasive and best way to prevent incontinent episodes.

Which statement by the nurse indicates an accurate understanding of primary encopresis? A. "Primary encopresis refers to a child who wets the bed at night." B. "Primary encopresis occurs when a child has not achieved toilet training." C. "Primary encopresis refers to a child who is not potty trained." D. "Primary encopresis occurs when, after a child was trained, they resort back to having toileting accidents daily."

Answer: B Encopresis is an abnormal elimination pattern characterized by recurrent soiling or passage of stool at inappropriate times by a child who should have achieved bowel continence. An estimated 1-2% of children younger than 10 years have encopresis, and approximately 80% of those children are boys. In addition, 80-95% of children with encopresis have a history of constipation. Children with primary encopresis have never achieved bowel control. Children with secondary encopresis have had bowel continence for several months.

Which statement by the nurse describes an isometric exercise that may be helpful in decreasing the occurrence of constipation? A. "Stretch your legs for 10 repetitions in the morning and 10 repetitions at bedtime." B. "Lie flat on your back and tighten the abdominal muscles for 10 seconds and then release them." C. "Lift a 5-pound weight from the floor to your waist." D. "Run on the treadmill for 20 minutes."

Answer: B Exercise assists in developing a regular defecation pattern. Weak abdominal and pelvic muscles contribute to irregular defecation patterns. The patient may be able to strengthen these muscles with the following isometric exercises: In a supine position, the patient tightens the abdominal muscles as though pulling them inward, holding them for about 10 seconds and then relaxing them. This exercise should be repeated 5-10 times each session and four times a day, depending on the patient's health. Lifting weights is more of a muscle-building exercise that doesn't necessarily address the abdominal muscles. Running on the treadmill is a cardiovascular exercise that is considered aerobic. Stretching the legs out is a great way to prevent contractures and prepare for mobility.

The nurse is reviewing the urinalysis test results conducted on a patient. The report states that the patient's urine appears cloudy. Which diagnosis should the nurse anticipate based on the urinalysis? A. High blood glucose levels B. Urinary tract infection C. Dehydration and fever D. Cirrhosis of the liver

Answer: B Hazy or cloudy urine indicates the presence of bacteria, pus, RBCs, WBCs, phosphates, prostatic fluid, spermatozoa, or urates, which can indicate a urinary tract infection. Concentrated or dark urine is found with dehydration and fever. Cirrhosis of the liver and hyperglycemia do not cause the urine to appear cloudy or hazy.

The nurse is caring for a patient with a history of heart failure, poor mobility, and urinary incontinence. The patient has a prescription for a diuretic, but the nurse notes that the patient has pitting edema in the lower extremities. Which question should the nurse ask first? A. "What is your normal dietary intake?" B. "Are you taking your diuretics as prescribed?" C. "Are you drinking enough fluids?" D. "Are you able to elevate your legs while sitting?"

Answer: B It is common for some older people to avoid taking their prescribed diuretics, especially when they have difficulty ambulating, because they are afraid of having an accident or having to get up to use the bathroom frequently. The patient's pitting edema is an indication that the patient is still retaining fluid. Fluid intake and dietary habits are important but are not the priority. Elevating the legs may be a useful intervention, but the nurse must assess the situation first.

A patient reports intense thirst, weight loss, and a large volume of urine when voiding. Which condition should the nurse suspect the patient is experiencing? A. Urgency B. Polyuria C. Enuresis D. Dysuria

Answer: B Polyuria can cause excessive fluid loss, leading to intense thirst, dehydration, and weight loss. The assessment findings do not describe enuresis, urgency, or dysuria. Enuresis is the involuntary passage of urine after toilet training has been well established at around 5 years of age. Urgency is a sudden strong desire to urinate. Dysuria refers to painful or difficult urination.

The nurse is preparing a teaching session about use of a pessary device for a patient with urinary incontinence. Which type of urinary incontinence should the nurse suspect? A. Overflow incontinence B. Stress incontinence C. Reflex incontinence D. Urge incontinence

Answer: B Stress incontinence can be treated with use of a pessary device. Urge incontinence can benefit from pelvic floor exercises and behavioral modifications. Reflex and overflow incontinence can benefit from the use of adult briefs and absorption devices.

The nurse is teaching a patient on the use of Kegel exercises for stress incontinence. Which patient statement indicates an understanding of the teaching provided? A. "I know they are working because my butt muscles are sore." B. "I am able to stop and start the urine stream." C. "I have practiced them and keep passing gas." D. "I should do these no more than once a day."

Answer: B The nurse would evaluate effective patient teaching when the patient states they are able to control the stream of urine by starting and stopping the flow. When the patient states that they are passing gas or the butt muscles are sore, the patient is not tightening the correct muscles and further teaching is needed. The exercises should be done twice a day initially and increase to four times a day.

The home health nurse is conducting an assessment of an older woman. Which observation should a nurse include to help determine the presence of urinary incontinence? A. Checking the odor of the patient's underwear B. Assessing for the odor of urine C. Palpating the bladder and noting any leakage D. Asking the patient directly about incontinence issues

Answer: B The process of observation uses all of the nurse's senses. Noting the odor of urine is an important assessment and can help bridge the conversation with the patient. Checking the patient's underwear is rather invasive and not appropriate for the nurse to do. Asking the patient about incontinence is not an observation technique. Palpating the bladder to look for leakage is not a valid observation mechanism by the nurse.

The nurse notes in the medical record that the patient's incontinence is related to an overactive detrusor muscle. Which type of urinary incontinence should the nurse suspect the patient is experiencing? A. Functional B. Urge C. Stress D. Overflow

Answer: B Urge incontinence is related to an overactive detrusor muscle, which increases bladder pressure. Stress incontinence is related to pelvic muscle relaxation and a weak urethra and surrounding tissues, which cause decreased urethral resistance. Overflow incontinence is related to a lack of normal detrusor muscle function, which causes the bladder to overfill and increases bladder pressure. Functional incontinence is related to the inability to respond to the need to urinate.

The nurse is caring for a group of patients on the medical-surgical unit. The nurse delegates some duties to the unlicensed assistive personnel (UAP). Which patient should the nurse instruct the UAP to provide care for first? A. A 71-year-old female who requires oral care after breakfast B. A 75-year-old bedbound man with an episode of urinary incontinence C. An 81-year-old female who requires routine morning hygiene care D. A postsurgical patient who needs help with ambulation

Answer: B Urinary incontinence can cause skin irritation and breakdown, especially in a patient who is bedbound. This patient should receive care first to minimize skin exposure to urine and the risk for pressure ulcers. The other patients who need routine oral care, morning hygiene, and assistance with ambulation are not the priority in this case.

The nurse is caring for a client who has a positive fecal test for occult blood. The nurse should anticipate which collaborative activity to further identify the cause of the​ client's problem? A. Ultrasonic bladder scan B. Colonoscopy C. Cystoscopy D. Direct rectal examination​ (DRE)

Answer: B ​Rationale: A positive occult blood test requires further testing for colon cancer or gastrointestinal bleeding due to peptic​ ulcers, ulcerative​ colitis, or diverticulosis. Colonoscopy is used to evaluate the colon and​ rectum; to detect​ polyps, cysts,​ tumors, or areas of inflammation and​ bleeding; and to remove tissue samples. Ultrasonic bladder scans are used to evaluate bladder emptying. Cystoscopy is used to evaluate the bladder wall and urethra and to remove small stones and tissue samples. DRE is performed to reveal abnormalities in the rectum and evaluate the strength of the sphincter muscles.

During a home​ visit, an older adult male client mentions that he has experienced an increase in the frequency of urination at night. Which condition should the nurse discuss as a possible factor related to increased urinary elimination at​ night? (Select all that​ apply.) A. Oliguria B. Nocturia C. Infection D. Residual urine E. Recognition of bladder fullness

Answer: B, C, D ​Rationale: The client is experiencing​ nocturia, which is the need to urinate two or more times at night. Residual urine or infection may be causing the client to experience this condition. Alterations in the ability to recognize bladder fullness is usually a result of neurologic impairment and results in the inability to control the urinary​ sphincters, frequently causing involuntary urination. Oliguria is a decrease in​ urination, which is the opposite of what this client is experiencing.

The nurse is assessing a patient with a history of urinary retention who is diagnosed with a urinary tract infection. When reviewing the patient's health history, which finding would most likely be the causative agent? A. Lack of performing Kegel exercises B. Decreased functional mobility C. Intermittent self-catheterization D. Alzheimer disease

Answer: C A patient performing intermittent self-catheterization would be at high risk for the development of a urinary tract infection due to the introduction of a foreign object into the sterile urinary tract. Lack of performing Kegel exercises, difficulty ambulating, and Alzheimer disease cause urinary incontinence, not retention and infection.

A nurse is caring for an 83-year-old patient with a history of urinary incontinence. What is the priority nursing diagnosis for this patient? A. Coping, Ineffective B. Tissue Perfusion: Peripheral, Ineffective C. Skin Integrity, Risk for Impaired D. Self-care Deficit: Toileting

Answer: C A patient with urinary incontinence is at risk for impaired skin integrity due to the excess moisture and friction to which the skin is subjected. There is no evidence that the patient has impaired perfusion or a self-care deficit. While the patient may have difficulty coping with urinary incontinence, it is not the priority in this situation.

The nurse is caring for a patient who reports frequent urination. The nurse asks about dietary intake during the focused assessment. Which product consumed by the patient should concern the nurse? A. Pickles B. Canned soup C. Alcohol D. Pretzels

Answer: C Alcohol is an example of a fluid that decreases production of antidiuretic hormone (ADH), which will increase urine output. Pickles, pretzels, and canned soup are all high in sodium and cause fluid retention.

A patient is experiencing increased urinary urgency and incontinence. Which medication should the nurse anticipate to be prescribed for this patient? A. Diuretic B. Cholinergic agent C. Anticholinergic agent D. Antiflatulent

Answer: C Anticholinergic agents affect the autonomic nervous system and are used to relieve symptoms associated with voiding in patients who have urge incontinence. Cholinergic agents are used to promote urination and simulate bladder contractions. Antiflatulents are used to reduce and treat excess gas. Diuretics promote removal of excess water and increase urination.

The nurse is caring for a patient who presents with severe diarrhea. The healthcare provider has ordered an antidiarrheal agent. Before administering the medication, the nurse reviews the most recent lab orders and notes that the patient is severely dehydrated and has an elevated blood urea nitrogen (BUN) and creatinine. Which is the priority action by the nurse? A. Withholding the medication and having the labs retested B. Administering the antidiarrheal agent and notifying the provider of the lab results C. Withholding the antidiarrheal agent and notifying the provider D. Administering the antidiarrheal agent and documenting the action

Answer: C Antidiarrheal agents are contraindicated in patients with severe dehydration, electrolyte imbalance, liver and renal disorders, and glaucoma. The nurse should withhold the medication and notify the provider. Administering the medication is not appropriate in light of these contraindications and the latest lab results. Rerunning the blood tests is a collaborative intervention and requires a physician order.

The nurse is caring for a 60-year-old patient being treated for constipation. Which procedure should the nurse teach the patient to help establish regular bowel movements? A. Kegel exercises B. Self-catheterization C. Digital stimulation D. Anal hygiene

Answer: C Bowel training/digital stimulation can be used or taught to the patient to establish regular defecation. Kegel exercises are useful in the treatment of urinary incontinence. Anal hygiene will not help to establish regular defecation. Self-catheterization is appropriate for a patient with urinary retention.

The nurse is observing a new graduate nurse provide care for a patient with Clostridium difficile (C. diff) infection. Which action by the new graduate nurse requires immediate intervention? A. Providing frequent perineal care B. Implementing strict isolation guidelines C. Washing hands with a hand sanitizer D. Washing hands frequently during patient care

Answer: C C. diff is a serious infection that causes frequent diarrhea. Nurses caring for a patient with a C. diff infection should wash their hands frequently using soap and water, not hand sanitizer. It's important to implement strict isolation precautions and provide perineal care as necessary.

Which patient with urinary incontinence would benefit most from using a bedpan and elevating the head of the bed? A. A patient with multiple sclerosis B. A patient with a wheeled walker C. A patient who is bedridden D. A patient who is pregnant

Answer: C Elevating the head of the bed and using a bedpan would be most beneficial for a patient who is bedridden. A patient with mobility issues such as using a wheeled walker and a pregnant patient would benefit from timed voiding. A patient with multiple sclerosis would benefit from catheterization.

A patient reports severe abdominal cramping and foul-smelling diarrhea. Which condition should the nurse suspect as the cause of these symptoms? A. Stomach cancer B. Diverticulitis C. Fecal impaction D. Constipation

Answer: C Fecal impaction can be recognized by the passage of liquid, foul-smelling fecal material (diarrhea) in the absence of formed stool. This occurs as the liquid portion of the feces seeps out around the impacted mass. The patient usually experiences abdominal cramping and a sensation of fullness in the rectal area. Constipation is defined as infrequent bowel movements and hard-to-pass stool. In most cases of stomach cancer, there are no symptoms, but at times the symptoms, such as severe diarrhea, are mistaken for a stomach virus. Diverticulitis is inflammation of one or more of the pouches in the digestive tract. Pain, abdominal tenderness, and fever are the common symptoms.

The nurse provided teaching to a patient about the relationship between diarrhea and fecal impaction. Which patient statement indicates effective teaching? A. "I may be eating too much food at night, causing my feces to become liquid." B. "I may be eating too many fried foods that is causing my feces to be loose and liquid." C. "I may have a blockage in my rectum that only allows liquid feces to get through." D. "I may have a bowel infection that has caused my feces to be liquid."

Answer: C Fecal impaction is a mass or collection of hardened feces in the folds of the rectum or colon. Impaction results from prolonged retention and accumulation of fecal material. In severe impactions, the feces accumulate and extend well up into the sigmoid colon and beyond. Fecal impaction can be recognized by the passage of liquid, foul-smelling fecal material (diarrhea) in the absence of formed stool. This occurs as the liquid portion of the feces seeps out around the impacted mass. Impaction also can be assessed by digital examination of the rectum, during which the hardened mass can often be palpated. Dietary issues such as eating too much food at night or eating an abundance of fried foods would not cause the buildup of stool in the rectum that produces an impaction. The symptoms of a bowel infection would show up as extreme pain, cramping, and explosive diarrhea.

During a checkup, a pregnant patient reports urinary incontinence. Which instruction is appropriate for the nurse to provide for this patient? A. Increasing fluid intake B. Consuming more fiber C. Performing Kegel exercises D. Avoiding alcohol

Answer: C Kegel exercises may help pregnant women maintain urinary muscle strength and prevent incontinence. Alcohol should be avoided during pregnancy, but abstinence will not address the concern of incontinence. Consuming fiber is an appropriate topic for a patient experiencing constipation. Increasing fluid intake will not help a patient with urinary incontinence.

A patient tells the nurse, "I have been taking magnesium hydroxide daily to help with the constipation I've had from my prescriptions." Which response by the nurse is correct? A. "This type of laxative should not cause any abdominal cramping." B. "This laxative may result in hypermagnesemia." C. "This type of laxative may lead to electrolyte disturbances that might affect your heart and lungs." D. "This type of laxative should produce a bowel movement within 12-18 hours."

Answer: C Magnesium hydroxide (MOM) can increase the risk of hypomagnesemia (not hypermagnesemia), which may result in cardiac dysrhythmias and respiratory failure. MOM can cause abdominal cramping and diarrhea, and usually produces a bowel movement within 24-72 hours.

The nurse taught a patient on the use of Milk of Magnesia (MOM). Which patient statement demonstrates effective teaching? A. "I can take MOM whenever I have constipation." B. "I can take MOM while I'm breastfeeding." C. "I should include MOM on my medicine list in case I am prescribed an antibiotic." D. "I should drink no more than 4 glasses of water when taking MOM."

Answer: C Magnesium hydroxide (MOM) may indeed interfere with some antibiotics, and should be shared with the caregiver. This drug works by increasing the amount of water in the intestines to soften stools; therefore, increasing liquids would be beneficial. MOM should not be used if pregnant or breastfeeding. Frequent use of MOM could lead to hypomagnesemia, causing cardiac dysrhythmias and respiratory failure.

The nurse is teaching the parents of a preschool-age child about the causes of nocturnal enuresis. Which statement is appropriate for the nurse to include in the teaching session with the parents? A. "It is common for children to develop incontinence when stressed." B. "Bedwetting is more common in girls than in boys." C. "Many children wet the bed due to difficulties in arousal from sleep." D. "Your child knows she can get away with this and is just being lazy."

Answer: C Nocturnal enuresis is especially prevalent in children who are reported to be deep sleepers, although it can occur at any stage of sleep, and occurs more often in boys. It can also be the result of overproduction of urine at night, and constipation. There is no indication that nocturnal enuresis is caused by the child being too lazy to get out of bed at night to urinate. Stress may play a role in incontinence in pregnant and older adults but not in preschool-aged children. Secondary nocturnal enuresis can be related to stress.

Which nonpharmacologic information should the nurse include when preparing a teaching session for a patient with a history of constipation? A. "Take a bulk-forming laxative each morning." B. "Drink 3-4 glasses of fluid per day." C. "Eat raw fruits and vegetables." D. "Take a protein supplement daily."

Answer: C Nonpharmacologic information the nurse needs to teach the patient includes eating raw fruits and vegetables and maintaining a regular exercise program. The patient needs to drink 6-8 glasses of fluid per day to avoid constipation. Taking a bulk-forming laxative or a protein supplement are pharmacologic interventions when managing constipation.

At 5 feet 10 inches and 320 pounds, a female patient has been advised to lose weight for her overall health and to help with a recent problem of incontinence. The patient asks, "How will this help with my incontinence?" Which explanation by the nurse is appropriate? A. "People who are overweight often have diabetes. One of the clinical manifestations of diabetes is overproduction of urine." B. "Obesity causes the bladder to empty at a predictable volume due to an inability to sense when the bladder is full." C. "Weight loss can reduce stress incontinence caused by increased pressure on the bladder as a result of obesity." D. "Obesity causes a lack of normal detrusor muscle activity. This leads to overfilling of the bladder and frequent leaks of small amounts of urine."

Answer: C Obesity is a risk factor for urinary incontinence, especially stress incontinence. This is most likely because of the excess force placed on the bladder. Not all patients with diabetes are obese and not all obese patients have diabetes. Reflex incontinence causes the bladder to empty at a predictable volume. Overflow incontinence is the lack of normal detrusor muscle function causing bladder overfilling and increased bladder pressure.

A patient states to the nurse, "I am worried about having this fecal impaction. What is it?" Which response by the nurse is most accurate? A. "This condition is a loss of voluntary control of defecation." B. "I can see why you are worried; it is a painful condition." C. "It is a collection of hardened feces in the rectum or colon." D. "I understand your concern, but it is really nothing to worry about."

Answer: C The nurse has knowledge of the disease process and is responsible for providing information to the patient when asked. Fecal impaction is a collection of hardened stool in the rectal area and the colon over an extended period of time. Constipation and fecal impaction affects older adults more frequently than younger adults. Telling the patient that it is nothing to worry about is not therapeutic. Acknowledging worry is therapeutic but does not address the patient's question. Fecal incontinence is the loss of voluntary control of defecation.

Which specific instruction should the nurse provide to a patient experiencing an alteration in bowel function? A. Instruction on prevalence of bowel problems B. Instruction on self-catheterization C. Instruction on increased fluid and fiber intake D. Instruction on fecal assessment

Answer: C The nurse should educate the patient on increased fluid and fiber intake. Instructions on self-catheterization, assessment of fecal matter, and the prevalence of bowel problems are not specific subjects taught to patients experiencing an alteration in bowel function.

A patient reports severe abdominal cramping, constipation, and some bowel leakage. Which action should be a part of the nurse's initial assessment plan? A. Providing prune juice B. Giving a cleansing enema C. Palpating the abdomen D. Increasing fluid intake

Answer: C The nurse should palpate the abdomen for firmness and tenderness and the presence of any mass (retained stool). The cleansing enema would be contraindicated in the case of an impaction. Increasing fluid intake and/or drinking prune juice would be interventions to avoid the impaction.

The nurse is caring for a 23-year-old female patient who is complaining of urinary frequency, and voiding a lot more than usual. How should the nurse document the patient's complaint? A. Urgency B. Urinary retention C. Polyuria D. Dysuria

Answer: C The nurse would document the patient's complaint as polyuria, which is the passage of large amounts of urine. Complete lack of voiding, incomplete bladder emptying, overflow incontinence, pain, constant urge to urinate, and weak urinary flow are signs of urinary retention. Dysuria is painful or difficult urination. Urgency is a sudden strong urge to urinate, regardless of the amount of urine in the bladder.

The nurse is evaluating a patient with stress incontinence due to weak pelvic floor muscles who continues to experience leakage. Which question should the nurse ask to investigate ongoing stress incontinence? A. "Are you having trouble ambulating?" B. "Have you decreased your fluid intake?" C. "Have you been performing Kegel exercises?" D. "Have you increased your fiber intake?"

Answer: C The nurse would investigate the use of Kegel exercises to strengthen the pelvic floor muscles in the patient with stress incontinence. Fluid intake would be investigated if timing with fluid intake and amount were the cause of incontinence. Fiber intake would be investigated in a patient with constipation. Ambulation issues would be indicated in the person with functional decline.

The nurse is caring for a patient diagnosed with urinary retention. Which medication on the patient's medical administration record should the nurse question? A. Acetaminophen B. Bethanechol chloride C. Diphenhydramine hydrochloride D. Ibuprofen

Answer: C The nurse would question the use of an antihistamine, such as diphenhydramine hydrochloride, for a patient with urinary retention. These medications can affect the autonomic nervous system and interfere with the normal urination process. Bethanechol chloride is a medication used to treat urinary retention. Acetaminophen and ibuprofen can be administered safely for a patient with urinary retention.

A older male patient is experiencing urinary retention. Which collaborative activity should the nurse anticipate for this patient? A. Renal ultrasound B. Cystoscopy C. Ultrasonic bladder scans D. Urinalysis

Answer: C Ultrasonic bladder scans are used to evaluate bladder emptying and to examine for residual urine. While a urinalysis, cystoscopy, and renal ultrasound are often prescribed for patients with alterations in urinary function, these tests will not diagnose the cause of the urinary retention the patient is experiencing.

The nurse educator is planning a presentation on involuntary urinary elimination for a group of new nurse graduates. The nurse educator should include which condition related to the types of involuntary urinary​ elimination? (Select all that​ apply.) A. Anuria B. Oliguria C. Enuresis D. Impaction E. Incontinence

Answer: C, E ​Rationale: The two types of involuntary urinary elimination are enuresis and urinary incontinence. Enuresis is repeated involuntary urination in children old enough for bladder control. Urinary incontinence is involuntary leakage of urine or loss of bladder control. Oliguria and anuria are alterations in urinary elimination but are not considered involuntary. Impaction is a term that refers to an accumulation of dry fecal contents in the bowel that cannot be expelled.

A female patient is experiencing problems with urinary elimination. After an initial assessment interview, the nurse performs a physical examination. Which specific assessment should the nurse include? A. Inguinal area assessment B. Perianal assessment C. Dietary assessment D. Skin assessment

Answer: D A focused nursing assessment of the urinary system includes a skin assessment, an abdominal assessment, a urinary meatus assessment, a kidney assessment, and a bladder assessment. Dietary, perianal, and inguinal area assessments would be appropriate for a patient experiencing an alteration in bowel function.

The mother of a 2-month-old infant is concerned about the frequency of her infant's bowel movements. Which response by the nurse addresses the mother's concern? A. "Meconium is usually passed in the first 24 hours of life." B. "Some control of defecation begins at this stage." C. "Infant bowel habits are similar to adult habits." D. "Infant bowel movement patterns change at this age."

Answer: D An infant's defecation pattern changes at the age of 1 to 2 months, but it is not similar to adult habits. Infants may have from one or more bowel movements per day to one bowel movement every 1-2 weeks. Breastfed infants usually have a higher frequency of bowel movements, and formula-fed infants are more prone to constipation. Infants cannot control defecation at 2 months and pass meconium only in the first day of life.

The nurse is caring for an older male with urinary problems. The patient has been ordered to have an ultrasonic bladder scan. The patient asks, "What is the purpose of the test?" How should the nurse reply? A. "To see how much pressure is in the urethra" B. "To look for bladder infection" C. "To look at how much urine is passed per second. D. "To see how much you empty your bladder"

Answer: D An ultrasonic bladder scan looks at residual volume to determine the degree of bladder emptying. An uroflowmetry test is performed to measure the volume of urine passed per second. Cystometrography can be used to evaluate urethral pressures. A urinalysis can look for signs of a bladder infection.

The nurse is preparing to administer an antidiarrheal agent to a patient with severe diarrhea lasting several days. Before administering the medication, what lab result(s) should the nurse check? A. Blood clotting panel B. Thyroid stimulating hormone (TSH) C. Hemoglobin (Hgb) D. Blood urea nitrogen (BUN) and creatinine

Answer: D Antidiarrheal agents are contraindicated in patients with severe dehydration, electrolyte imbalance, liver and renal disorders, and glaucoma. The nurse should check the most recent BUN and creatinine levels and withhold the medication if they are elevated. TSH level evaluates the thyroid gland; abnormal levels are not contraindicated in the administration of an antidiarrheal agent. An abnormal hemoglobin level can indicate anemia; it is not contraindicated for the administration of an antidiarrheal. Antidiarrheals are not contraindicated in patients with abnormal blood clotting factors.

The nurse is caring for a patient who reports urine leakage with laughter and coughing. Which is an appropriate assessment for the nurse to perform? A. Capillary refill B. Lung sounds C. Bilateral strength the inner thigh muscles D. Bulging of the bladder into the vagina when bearing down

Answer: D Assessment for bulging of the bladder into the vagina when bearing down aligns with assessment for continence. The inner thigh muscles, lung sounds, and capillary refill are not items that indicate urinary incontinence.

A patient reports abdominal cramping, pain, and constipation. Which question should the nurse ask the patient during the health history? A. "Are you eating a diet high in fats?" B. "Are you taking anything for your allergies?" C. "Are you taking protein supplements?" D. "Are you taking any pain medication?"

Answer: D Constipation can be a side effect of certain medications (e.g., opioids, iron supplements, antihistamines, antacids, antidepressants). Many factors increase a patient's risk for constipation, including insufficient activity, immobility, irregular defecation habits, changes in daily routines, lack of privacy, chronic use of laxatives or enemas, irritable bowel syndrome, pelvic floor dysfunction or muscle damage, and poor motility or slow transit. Protein supplements are used for patients who want to bulk up, such as body builders. They are also used in patients who have a difficult time absorbing protein. Allergy medications have side effects such as dry mouth, dizziness, nausea and vomiting, and drowsiness. A diet high in fats would most likely produce diarrhea as a side effect.

The nurse is reviewing the medication list with a pregnant patient who is complaining of painful incidences of constipation. Which should the nurse suggest as the cause of the patient's symptoms? A. Drinking 6-8 glasses of water daily B. Taking guaifenesin in the morning C. Following a high-fiber diet D. Taking ibuprophen for discomfort

Answer: D Constipation can be a side effect of taking an NSAID for discomfort. These medications having a constipating effect. Following a high-fiber diet and drinking the recommended amount of water daily is a nonpharmacologic intervention to avoid the issue of constipation. Guaifenesin is a medication used to thin mucus to help make it easier to clear from the patient's head, throat, and lungs.

The nurse taught the parents about the possible causes of constipation the toddler has experienced. Which statement made by the parent demonstrates effective teaching? A. "My child is drinking too many fluids." B. "My child is not eating enough protein." C. "My child has encopresis." D. "My child may be holding it in because the bathroom is unfamiliar."

Answer: D Constipation occurs most frequently in toddlers and preschoolers and is often associated with learning to control body functions. Many toddlers do not like the sensations of a bowel movement and may begin withholding stool or hiding from parents until the urge to defecate has passed. The stool accumulates in and dilates the rectum until the next urge to defecate, often after the next meal. Stool withholding can lead to hard stools and painful defecation, causing the child to avoid the experience. Passing the hard stool could be traumatic, causing a tear in the mucosal tissue of the rectum or anus. Constipation may occur as a result of limited time for toileting. Busy school-age children may delay toileting to participate in other activities, and adolescents participating in sports or other extracurricular activities may have limited time for toileting. Children may also be hesitant to use an unfamiliar bathroom. Eating a diet high in protein is encouraged for patients who are body builders or have had a surgical procedure that limits the absorption of protein. Drinking an excess of fluids would not cause the patient to be constipated, but it is often listed as an intervention for constipation. Encopresis is voluntary fecal incontinence from a child who is already toilet trained.

The nurse is caring for an older adult patient in a long-term care setting. The patient's family states, "With our mother's recent memory lapses, we are concerned about her recent urinary accidents." Which statement by the nurse best addresses the patient's risk for urinary incontinence? A. "We can insert a urinary catheter." B. "We can get your mother a wheeled walker to help in getting to the bathroom." C. "There are medications we can give your mother." D. "We can institute scheduled toileting for your mother."

Answer: D Dementia is a risk factor for urinary incontinence, because the patient may not have the cognitive ability to reach the bathroom in time. Therefore, timed voiding would be the least invasive and best way to prevent incontinent episodes. An internal catheter would increase the risk for infection. Medications may increase confusion. A person with dementia may not have impaired ambulation; this would be best for a patient with functional incontinence due to impaired mobility.

A parent reports that their 5-year-old child has never been able to achieve bowel control. Which condition should the nurse suspect? A. Growth retardation B. Pyschosocial issues C. Secondary encopresis D. Primary encopresis

Answer: D Encopresis is an abnormal elimination pattern characterized by recurrent soiling or passage of stool at inappropriate times by a child who should have achieved bowel continence. Children with primary encopresis have never achieved bowel control. Children with secondary encopresis will have bowel continence for several months. Psychosocial issues for children related to bowel complications would be problems with using toilets that are not in their home, being afraid to ask to use the restroom in school, or being so busy that they forget to go to the bathroom. Growth retardation is used to define the statistics on how a child grows and progresses through their adolescence. This particular factor has no effect on bowel incontinence.

A patient presents to the nurse with complaints of urine leakage with constipation. Which dietary change should the nurse advise to the patient to help diminish urinary incontinence? A. Increasing alcohol B. Increasing spicy food C. Increasing caffeine D. Increasing fiber

Answer: D Increasing fiber will combat constipation, helping to prevent stress incontinence. Caffeine, alcohol, and spicy food all contribute to irritation of the bladder, which would promote urinary incontinence.

The nurse is admitting a patient in the emergency department for acute diarrhea. Which is the priority assessment question the nurse should ask? A. "Have you had any incontinence with the diarrhea?" B. "What amount of fluid do you drink each day?" C. "What time of day do you usually have a bowel movement?" D. "How often are you having diarrhea?"

Answer: D It is most important for the nurse to ask about the symptoms of diarrhea, including when and how often the symptoms occur. Questions about incontinence, normal bowel movement patterns, and regular fluid intake are important but are not the priority for this patient.

Which drug acts by increasing stool bulk and promoting the passage of stool? A. Milk of Magnesia B. Bismuth subsalicylate (Kaopectate) C. Bisacodyl D. Methylcellulose (Citrucel)

Answer: D Methylcellulose (Citrucel) is a bulk-producing laxative that restores the normal moisture level and bulk content of the intestinal tract. In treating constipation, a bulk-producing laxative retains free water in the intestinal lumen, thereby indirectly opposing the dehydrating forces of the bowel. This action helps the formation of a normal stool. Milk of Magnesia (MOM) contains poorly absorbed salts and stimulates peristalsis by irritating the bowel mucosa. MOM is a stimulant, not solely a bulking agent used for the prevention of constipation. Bisacodyl is a laxative that stimulates intestinal motility and secretions. It is not a bulk-forming agent for the prevention of constipation. Bismuth subsalicylate (Kaopectate) is used to treat diarrhea, not constipation.

The nurse is teaching the parents of a new baby about bowel elimination. Which instruction should the nurse include? A. Formula-fed infants pass stool more frequently than will breastfed infants. B. Constipation is common in the first few days of life, especially in breastfed infants. C. Newborns dirty their diaper up to 10 times per day in the first few days of life. D. Newborns pass meconium within the first 48 hours.

Answer: D Most newborns will pass meconium, a black and tar-like stool, within the first 6-24 hours of life, up to 48 hours. Meconium will begin to transition to fecal material within the first few days. Infants (not newborns) will pass stool up to 10 times per day. Formula-fed infants are more likely to become constipated and tend to pass stool less frequently than do breastfed infants.

Which is the cause of fecal incontinence in a pregnant woman who is 21 weeks' gestation? A. Extremely large fetus B. Obesity C. Movement of the fetus D. Pelvic floor dysfunction

Answer: D Pregnancy after 20 weeks, regardless of mode of delivery, greatly increases the prevalence of major pelvic floor dysfunction, including all types of incontinence. Anal canal volume (ACV) increases by 20% between 18 and 28 weeks of pregnancy, and there is significant association between ACV and incontinence scores. Many of the problems associated with postpartum changes in the pelvic floor may be attributed to biomechanical changes occurring in pregnancy. Exercise assists in developing a regular defecation pattern. Weak abdominal and pelvic muscles contribute to irregular defecation patterns. The size of the fetus would not have a direct correlation to producing episodes of fecal incontinence. An obese patient who is pregnant may have difficulty with breathing and mobility issues. Fetal movement is described throughout the complete pregnancy term but it does not describe any relationship to causing episodes of incontinence.

An older male patient is experiencing dysuria and urinary retention. The nurse should suspect which condition first as the most likely cause of these clinical manifestations? A. Polyuria B. Renal failure C. Anuria D. Prostatic hyperplasia

Answer: D Prostatic hyperplasia (BPH), which is enlargement of the prostate, can cause urinary retention, dribbling at the end of urination, incontinence, and nocturnal enuresis. Renal failure does not cause dysuria or retention. Polyuria is a term that describes an increase in urination. Anuria is the absence of urination.

The nurse preceptor is reviewing the plan of care for a patient with urinary incontinence created by a graduate nurse. Which dietary intervention submitted by the graduate nurse should the preceptor correct? A. Promoting a diet that is high in fiber B. Avoiding bladder irritants C. Altering nutrition to maintain a healthy weight D. Restricting fluid intake

Answer: D The care plan for the patient with urinary incontinence should include nutrition that maintains a healthy weight; a high-fiber diet to prevent constipation; avoidance of bladder irritants such as alcohol, caffeine, acidic food, and spicy food; and maintenance of adequate fluid intake. Adequate fluid intake is vital to promote hydration and urinary function. Overly concentrated urine can irritate the bladder, increasing incontinence.

An older adult patient asks why they are having difficulty making it to the bathroom on time lately. Which response by the nurse is accurate? A. "The bladder muscles get stronger over time, making it difficult for you to relax for urination." B. "The diuretics that you take cause you to retain urine." C. "You have a lower level of a hormone that makes it hard for you to control urination." D. "The muscles under your bladder become weakened with age, making it difficult to control urine flow."

Answer: D The muscles in the pelvic floor situated under the bladder (as shown below) weaken with age, which can make it more difficult for the patient to control the flow of urine. The bladder detrusor muscles also weaken, not strengthen, making it difficult to contract proficiently and completely empty the bladder. Diuretics cause increased urine output, not urine retention. Older adults have higher, not lower, levels of antidiuretic hormone (ADH).

The nurse is caring for a patient in a long-term care facility who has not had a bowel movement in 5 days. The unlicensed assistive personnel reports that the patient is passing a very small amount of liquid stool. Which should be the nurse's first action? A. Administer a prescribed laxative. B. Document the findings. C. Advise the healthcare provider of the situation. D. Check the patient for an impaction.

Answer: D The nurse needs to check the patient for an impaction because liquid stool is likely to seep around the impaction. Smearing of liquid stool is a common symptom of an impaction. Prior to notifying the healthcare provider, the nurse should conduct an assessment that includes palpation of the abdomen for firmness or tenderness as well as for the presence of any mass (retained stool). Bowel sounds should also be assessed. If a direct digital examination (DRE) is allowed by agency policy, the nurse should assess for the presence of stool in the rectum. A laxative may be appropriate in the future, but not initially. The nurse needs to record the findings, but only after adequately assessing the patient for impaction.

The nurse is assessing a patient who is 2 weeks postoperative hip replacement surgery and presents with severe abdominal pain and a complaint of constipation. Which should the nurse suspect as a possible cause of the gastrointestinal symptoms? A. Dehydration B. Blood loss C. Surgical infection D. Pain medication

Answer: D The nurse should conduct a full review of medications in use and discuss with the patient and caregiver with each assessment and evaluation of outcomes. Constipation is a side effect of many pain medications, especially those of the opioid classification. These medications cause constipation, because they slow down bowel motility. A surgical infection would present itself as red, painful, hot to the touch, and possible drainage from the site. A dehydrated patient would present with fatigue and dizziness, as well as urine that is darker and more concentrated, and an increased pulse rate may be seen. Significant blood loss following a surgery would manifest as a medical emergency and may require a transfusion or result in shock.

The nurse is caring for a patient with urinary incontinence related to a urinary tract infection. Which diagnostic test would indicate if a urinary tract infection is contributing to urinary incontinence? A. Bladder diary B. Postvoid residual C. 24-hour urine sample D. Urinalysis

Answer: D Urinalysis is used to diagnose the presence of a urinary tract infection which contributes to the occurrence of urinary incontinence. A bladder diary helps to diagnose the patient's type of incontinence. A 24-hour urine sample provides information on kidney and bladder function. Postvoid residual reveals retention of urine for further investigation of cause.

Which factor should the nurse consider as a contributing cause of urinary incontinence in older adult patients? A. Urine concentration B. Internal sphincter C. Micturition D. Impaired mobility

Answer: D Urinary incontinence in the older adult may be caused by impaired mobility, impaired vision, dementia, and lack of access to toileting facilities and privacy. Urine concentration, micturition, and the internal sphincter are not causes of urinary incontinence.

A pregnant patient asks the nurse, "Is there anything I can do to help with my fecal incontinence?" Which response by the nurse is most accurate? A. "We can discuss utilizing an exercise bike." B. "We can discuss the changes caused by prenatal vitamins." C. "We can discuss the benefit of dietary changes." D. "We can discuss the benefit of Kegel exercises."

Answer: D When performed correctly and regularly, exercises for pelvic floor muscles will enable this muscle group to accomplish the task of supporting the structures in the pelvis. Everyone can benefit from exercising this muscle group. The nurse will include teaching interventions when planning care for women with urinary stress incontinence, men with urinary stress incontinence after prostate surgery, and anyone with bowel incontinence problems. Using an exercise bike will not necessarily strengthen pelvic floor muscles. Diet and prenatal vitamins have little effect on fecal incontinence.

The nurse is providing home care instructions for a patient with fecal incontinence. Which information should the nurse include? A. Reduce fluid intake. B. Decrease usage of bulk-forming laxatives. C. Eat a low-fiber diet. D. Maintain good skin care.

Answer: D When providing home care teaching with a patient experiencing fecal incontinence, the nurse needs to educate the patient about maintaining good skin care for fecal incontinence because it can cause skin breakdown. The patient should use bulk-forming laxatives to provide stool bulk and reduce the number of small, liquid stools. The patient needs to consume a high-fiber diet and drink ample fluids to help in maintaining soft, well-formed stools.

The father of a​ 3-year-old boy is concerned that his child still wets the bed at night. Which explanation by the nurse is most appropriate regarding​ bedwetting? A. ​"Oliguria is not uncommon in​ children." B. ​"By 24​ months, children are capable of holding urine beyond the urge to​ void." C. ​"Sometimes children experience​ nocturia." D. ​"Children often achieve daytime bladder control prior to nighttime​ control."

Answer: D ​Rationale: Bladder control is attained by ages 2 to 5​ years, often with daytime control attained prior to nighttime control. Oliguria is scant urine​ output, and the other statements by the nurse do not address the​ father's concern.

A breastfeeding mother of a​ 2-month-old infant is concerned that her son defecates too frequently. Which response by the nurse should address this​ mother's concern? A. ​"The increased frequency in defecation means your baby is at risk of weight​ loss." B. ​"Feces containing less water may be difficult for infants to​ expel." C. ​"Your baby should be able to control defecation by​ now." D. ​"Frequent bowel movements can occur with​ breastfeeding."

Answer: D ​Rationale: Frequent bowel movements often occur with​ breastfeeding; therefore, this response is the most appropriate. There is no indication that the infant is losing weight. Control of defecation is not expected at 2 months of age. While feces that contain less water may be difficult to​ pass, the infant is not experiencing hard stools.

A nurse is assessing a client who is complaining of black stools. About which medication that the client might be taking should the nurse​ inquire? A. Antacids B. Stool softener C. Antibiotics D. Iron supplements

Answer: D ​Rationale: The oxidation of iron in supplements can cause the stools to appear​ black; the nurse should ask about any vitamins and supplements that the client is taking. Antacids can cause the stools to appear whitish or have white specks. Antibiotics can cause a​ gray-green discoloration. Stool softeners do not alter the color of stool.

The nurse should anticipate conducting which assessment when preparing to provide care for a client experiencing alterations in bowel​ function? (Select all that​ apply.) A. Client interview B. Skin assessment C. Renal assessment D. Abdominal assessment E. Inguinal area assessment

Answer; A, B, D, E ​Rationale: Client​ interview, abdominal​ assessment, and inguinal area assessment are used to assess clients experiencing alterations in bowel function. A skin assessment should be conducted to the​ anal, perineum, and buttocks if the alteration involves diarrhea or frequent loose stool. A renal assessment is more appropriate for alterations in urinary elimination.

The daughter of a​ wheelchair-bound older adult client is concerned because her mother has been experiencing urinary incontinence. Which statement should the nurse use to explain the condition to the​ daughter? A. ​"Mobility issues may cause urinary​ incontinence." B. ​"The kidneys reach maximum size at ages 35 to​ 40." C. ​"Renal blood flow and ability to concentrate urine decrease in older​ adults." D. ​"The frequency of voiding varies in older adults and may cause urinary​ incontinence."

​Answer: A Rationale: Both mobility and neurological issues may cause urinary incontinence. The other explanations do not address the​ daughter's concern regarding her​ mother's urinary incontinence. Kidney size is unrelated to urinary incontinence. The excretory function of the kidneys diminishes with​ age, but not significantly enough below normal levels unless caused by a contributing disease process. The frequency of voiding varies for all individuals.