Elimination Questions
A client admitted to the hospital with a diagnosis of gout has also been diagnosed with uric acid renal calculi. When planning meals for this client, which diet will the nurse anticipate? A) Low-purine diet B) Low-sodium diet C) A diet high in calcium D) A diet low in calcium
A) Low-purine diet Rationale: A low-purine diet is appropriate in the management of a client with uric acid renal calculi. A low-sodium diet is useful in the management of a client with cystine renal calculi, and a diet limiting foods high in calcium is useful when managing a client with calcium phosphate renal calculi.
A client presents in the emergency department exhibiting signs indicative of the onset of a bowel obstruction. Which bowel sounds should the nurse anticipate when auscultating the client's abdomen? A) Gurgling or clicking sounds B) High-pitched tinkling, rushing, or growling sounds C) Absence of sounds D) Continuous medium-pitched hum
B) High-pitched tinkling, rushing, or growling sounds Rationale: High-pitched tinkling, rushing, or growling bowel sounds-known as borborygmus-are indicative of the onset of bowel obstruction. Gurgling or clicking sounds are considered normal. Absence of bowel sounds is indicative of late bowel obstruction, not onset of bowel obstruction. A continuous medium pitched hum-called a venous hum-is indicative of a cirrhotic liver.
The nurse is providing care to a client who is diagnosed with benign prostatic hyperplasia (BPH). Which items in the client's health history indicate a risk factor for this diagnosis? Select all that apply. A) Excessive exercise B) Decreased fluid intake C) Diet high in milk D) 70 years of age E) African American ethnicity
D) 70 years of age E) African American ethnicity Rationale: Although the exact cause is unknown, risk factors associated with BPH include increasing age. No link has been made to fluid intake, milk, or exercise.
The nurse is caring for a client diagnosed with benign prostatic hyperplasia (BPH) who is experiencing an increase in symptoms. Which statement by the client would best explain the source of the increased symptoms? A) "I have decreased oral intake at night." B) "I recently had a vasectomy." C) "I am using an over-the-counter cold medication for a cold." D) "I am drinking very little caffeine."
C) "I am using an over-the-counter cold medication for a cold. Rationale: Use of cold medications can increase symptoms because of their anticholinergic properties. Avoiding caffeine and decreasing oral intake at night may resolve symptoms. A vasectomy does not affect the symptoms of BPH.
The nurse is reviewing discharge instructions with the mother of a toddler who was hospitalized for constipation. Which statement made by the toddler's mother indicates the need for further education? A) "I should recognize that when my child walks stiffly on his tiptoes, this could indicate withholding." B) "Rocking and crossing the legs could be a sign of withholding." C) "I need to make sure my child eats a low-fiber diet." D) "Soiling could be a sign of withholding because of involuntary overflow."
C) "I need to make sure my child eats a low-fiber diet." Rationale: This child requires a diet that is high in fiber. This statement indicates the need for further instruction. All of the other statements made by the toddler's mother indicate appropriate understanding of the information presented regarding constipation.
Fecal impaction is a mass or collection of hardened feces in the folds of the rectum or colon as a result of prolonged retention and accumulation of fecal material. Which clinical manifestation is common in cases of fecal impaction? A) No passage of stool or fecal material of any kind B) Passage of soft, formed stools C) Passage of lumpy stools that are hard and dry D) Passage of liquid, foul-smelling fecal material in the absence of formed stool
D) Passage of liquid, foul-smelling fecal material in the absence of formed stool Rationale: Clients with a fecal impaction pass liquid, foul-smelling fecal material in the absence of formed stool; this is the liquid portion of the feces that seeps around the impacted mass. Passing no stool or fecal material is indicative of an obstruction. Soft, formed stools are generally considered normal. Lumpy stools that are hard and dry are indicative of constipation.
The nurse educator is speaking with a group of students about renal disorders. Which statement is appropriate for the educator to include regarding renal stones? A) Older adult clients are particularly at risk for urolithiasis. B) Young- or middle-adult men are at an increased risk for stones. C) Women have a greater risk overall than men. D) Frequency of stones is greater in the northern United States.
B) Young- or middle-adult men are at an increased risk for stones. Rationale: Men who are in young to middle age are affected 2-3 times more than women of that age. The frequency of the occurrence of renal stones in the United States is greatest in the southern and mid-western states.
The nurse is preparing to teach a class on the prevention of constipation. Which food choice will the nurse include as an example of a high-fiber food? A) Raw fruits B) Cooked vegetables C) White bread D) Cooked fruits
A) Raw fruits Rationale: Foods high in fiber include raw fruits, bran products, and whole grain products. Low-fiber foods would include cooked fruits, cooked vegetables, and white bread.
The nurse is caring for a client who is experiencing intermittent constipation. The client has been advised to increase the amount of dietary fiber. Which food selections by the client indicate that teaching has been effective? Select all that apply. A) Rice B) Carrot slices C) Spinach salad D) Bananas E) Peas
B) Carrot slices C) Spinach salad E) Peas Rationale: Dietary fiber increases stool bulk. Vegetable fiber—such as that in carrot slices, spinach, and peas—is an excellent source of dietary fiber. The remaining selections are examples of constipating foods.
The nurse is planning care for a newly admitted bed-bound older adult client. Which nursing diagnosis would be most appropriate for this client? A) Risk of Bowel Incontinence B) Disturbed Body Image C) Risk for Diarrhea D) Risk for Constipation
D) Risk for Constipation Rationale: ) Lack of activity, like being bedbound, is a major contributor to constipation. Lack of movement slows bowel movements. Lack of sphincter control, not bedrest, contributes to bowel incontinence. Diarrhea would come from a GI upset triggered by diseases, medication, or diet. Disturbed Body Image would affect a client who has undergone a bowel diversion.
A client is complaining of dull flank pain. List the order of the steps the nurse should take in conducting the physical assessment for this client. 1. Instruct the client. 2. Assess the general appearance. 3. Position the client. 4. Inspect the abdomen for color, contour, symmetry, and distention
1. Instruct the client. 3. Position the client. 2. Assess the general appearance. 4. Inspect the abdomen for color, contour, symmetry, and distention Rationale: : A quick survey of the client enables the nurse to identify any immediate problem as well as the client's ability to participate in the assessment. Begin the examination with the client in a supine position with the abdomen exposed from the nipple line to the pubis. Assess general appearance and inspect the client's skin for color, hydration status, scales, masses, indentations, or scars.
A client admitted to the hospital with a diagnosis of inflammatory bowel disease has also been diagnosed with calcium phosphate renal calculi. When planning care for this client, which type of medication does the nurse anticipate based on the data? A) Antibiotic B) Allopurinol C) Nonsteroidal anti-inflammatory drug (NSAID) D) Thiazide diuretic
D) Thiazide diuretic Rationale: A thiazide diuretic is used to prevent the formation of calcium stones. Allopurinol is often prescribed to prevent stones that tend to form in acidic urine (uric acid). Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat pain and discomfort and may reduce the amount of narcotic analgesia required for acute renal colic. Antibiotics are used to help prevent struvite stones.
A client in the ambulatory care clinic tells the nurse about experiencing frequent constipation. The nurse inquires about the client's diet. Which statement from the client would be of greatest concern for the nurse? A) "I like to eat a bran muffin and applesauce every morning for breakfast." B) "I like to eat popcorn for an afternoon snack." C) "I like to eat cheese, a banana, and a turkey sandwich for lunch." D) "I like to eat baked chicken, whole grain rolls, and a small salad for dinner."
C) "I like to eat cheese, a banana, and a turkey sandwich for lunch." Rationale: Both cheese and bananas are constipating foods that should be limited. The remaining selections are not associated with constipation.
The nurse conducts education for a client who is experiencing urinary incontinence. Which statement by the client indicates the need for further education? A) "Relaxation of pelvic muscles may be a factor in incontinence." B) "Reduced urethral resistance can be a cause of incontinence." C) "Incontinence is normal with aging." D) "A disturbance of my bladder is a factor in the development of incontinence."
C) "Incontinence is normal with aging." Rationale: Age is a risk factor for incontinence, but incontinence is not a normal result of aging. A disturbance of the bladder, relaxation of the pelvic muscles, and reduced urethral resistance are all potential factors in the development of incontinence.
The nurse is assessing an adult client in a urology clinic. The client reports that she has been having "accidents" and expresses frustration about this "normal part of aging." Which response by the nurse is the most appropriate? A) "Tell me more about the incontinence you are experiencing." B) "You may need to have surgery to manage this problem." C) "I understand you are frustrated about this occurrence." D) "Unfortunately, aging and incontinence go hand in hand."
A) "Tell me more about the incontinence you are experiencing." Rationale: As the body ages, there are anatomic changes that can increase the risk for urinary incontinence; however, this is not a normal part of aging. It is appropriate for the nurse to gather more information regarding the client's incontinence. It is beyond the nurse's scope of practice to recommend surgery to the client. Telling the client the nurse understands does not help to determine the cause of the client's incontinence.
The nurse provides education and supportive assistance for the family of a preschool-age client diagnosed with encopresis. Which statement indicates parental understanding of appropriate care? Select all that apply. A) "We will establish a limited schedule of activities that has many breaks to provide opportunities to use the toilet regularly." B) "We will schedule an appointment with a play therapist to help our older child adjust to our new baby." C) "We won't change our child's diet because we were afraid it will be stress provoking." D) "We will work on regular elimination after morning and evening meals." E) "We will continue to punish our child for having accidents as the behavior is learned and attention seeking."
A) "We will establish a limited schedule of activities that has many breaks to provide opportunities to use the toilet regularly." B) "We will schedule an appointment with a play therapist to help our older child adjust to our new baby." D) "We will work on regular elimination after morning and evening meals." Rationale: The underlying constipation that leads to encopresis may be caused by the stress of a full schedule of activities or other environmental changes (e.g., birth of a sibling). Dietary changes including incorporating high-fiber foods and limiting refined and highly processed foods and dairy products may be helpful. It takes several months for the bowel to be retrained to respond to sphincter stimulation. It is inappropriate to punish the child for having the accidents because they cannot be helped due to the underlying constipation.
The nurse is providing care to newborns in the nursery. When assessing the newborns' urinary output, which does the nurse anticipate as normal daily urinary output? A) 15-60 mL B) 100-300 mL C) 250-450 mL D) 400-500 mL
A) 15-60 mL Rationale: Normal urinary output for the newborn at 1-2 days of age is 15-60 mL per day. Normal urinary output for a newborn 3 to 10 days of age is 100-300 mL per day. The normal output for the newborn at 10 days of age to the infant at 2 months of age is 250-400 mL per day. Normal output for an infant at 2 months of age through 1 year is 400-500 mL per day.
A novice nurse is providing care to clients on a urology unit. When providing care to a group of clients, which client does the novice nurse identify as being at the greatest risk for developing urinary stones? A) A 35-year-old woman with quadriplegia from an auto accident B) A 65-year-old man with a recent history of myocardial infarction C) A 50-year-old man with type 2 diabetes mellitus D) A 25-year-old woman with several episodes of urinary infection
A) A 35-year-old woman with quadriplegia from an auto accident Rationale: The 35-year-old woman with quadriplegia from an auto accident experiences prolonged immobility, which will increase calcium loss from bones and therefore increase the chance of calcium stones precipitating in the urinary system. A 65-year-old man with a recent history of myocardial infarction, 50-year-old man with type 2 diabetes mellitus, and 25-year-old woman with several episodes of urinary infection do not have as great a risk because they do not remain immobile for long periods of time.
The nurse at a health fair is educating clients on risk factors associated with urinary incontinence. Which risk factor does the nurse include as a nonmodifiable risk factor for urinary incontinence? A) Age B) Obesity C) Smoking D) Diabetes
A) Age Rationale: Age is a nonmodifiable risk factor and is a primary risk factor for the development of urinary incontinence; older individuals experience more frequent incontinence than younger individuals. Obesity, smoking, diabetes, inactivity, pregnancy, and depression are all modifiable risk factors for urinary incontinence.
The nurse is caring for a client with chronic constipation. Which findings in the client's health history could be the cause of the current constipation? Select all that apply. A) Bedrest B) High-fiber diet C) Low-fiber foods D) Chronic laxative use E) Depression
A) Bedrest C) Low-fiber foods D) Chronic laxative use E) Depression Rationale: Factors that contribute to chronic constipation include lack of activity, such as bedrest; a diet low in fiber; chronic laxative use; and emotional disturbances such as depression. A high-fiber diet is a treatment option for chronic constipation.
The client admitted with benign prostatic hyperplasia (BPH) is prescribed an alpha-adrenergic blocker, prazosin (Minipress), for the treatment of BPH. When providing care to this client, which assessment is a priority related to this medication? A) Blood pressure B) Pain rating C) Respiratory rate D) Temperature
A) Blood pressure Rationale: The medication prazosin (Minipress) is an alpha-adrenergic blocker that may cause first-dose phenomenon (severe hypotension and syncope) and tachycardia. When administering this medication to a client diagnosed with BPH, the priority assessment is the client's blood pressure.
In which of the following ways do calcium phosphate stones differ from uric acid and cystine stones? A) Calcium phosphate stones are associated with alkaline urine, while uric acid and cystine stones are associated with acid urine. B) Calcium phosphate stones are associated with acid urine, while uric acid and cystine stones are associated with alkaline urine. C) Calcium phosphate stones are associated with alkaline urine, while uric acid and cystine stones are associated with neutral urine. D) Calcium phosphate stones are associated with neutral urine, while uric acid and cystine stones are associated with acid urine.
A) Calcium phosphate stones are associated with alkaline urine, while uric acid and cystine stones are associated with acid urine. Rationale: Calcium phosphate stones are associated with alkaline urine, while uric acid and cystine stones are associated with acid urine. None of the types of stones discussed are associated with urine that has a neutral pH.
The nurse admits a client to the medical unit for a urinary disorder. Which questions are appropriate for the nurse to include when assessing the client's voiding pattern? Select all that apply. A) How many times do you urinate in a 24-hour period? B) Has your pattern of urination changed recently? C) How often do you get out of bed at night to urinate? D) What color is your urine? E) Does your urine have any type of odor?
A) How many times do you urinate in a 24-hour period? B) Has your pattern of urination changed recently? C) How often do you get out of bed at night to urinate? Rationale: When assessing the client's voiding pattern it is appropriate for the nurse to ask how many times the client voids in a 24-hour period; if the pattern of urination has change frequently; and how often the client gets out of bed at night to urinate. Questions regarding the color and odor associated with urine are appropriate when assessing urine characteristics.
The nurse is caring for a client with a history of urinary tract infections (UTIs). Which action by the nurse would decrease the risk of the client experiencing future UTIs? A) Instruct the client to avoid delaying urination. B) Tell the client to increase caffeine in the diet. C) Encourage the client to use the pelvic floor muscles to force urine flow. D) Remind the client to wipe from back to front.
A) Instruct the client to avoid delaying urination. Rationale: Suppressing urination increases the risk of urinary tract infections. The pelvic floor muscles should not be used to force urine flow, and doing so is considered a poor toileting habit. The client should wipe from front to back because wiping from back to front would contaminate the urinary meatus. The client should decrease the use of caffeine in the diet because caffeine is a bladder irritant.
Inadequate fluid intake slows the passage of chyme along the intestines. This slowed passage increases the absorption of fluid from the chyme. How does this decreased intake and increased passage time affect the feces expelled from the body? A) It is drier and harder than normal. B) It is more watery and more soft than normal. C) It is more watery and harder than normal. D) It is drier and more soft than normal.
A) It is drier and harder than normal Rationale: When fluid intake is inadequate or output is excessive, the passage of chyme slows and the absorption of fluid increases. The end result is feces that is harder and drier than normal. Watery, soft feces is the result of rapid intestinal transit that leads to inadequate fluid absorption.
The nurse is providing training for the clinical staff of a skilled care facility that primarily treats elderly clients. The nurse wants to include information on functional incontinence. Which risk factors for functional incontinence will the nurse include in the training? Select all that apply. A) Limited mobility B) Impaired vision C) Lack of access to facilities D) Dementia E) Urinary tract infection
A) Limited mobility B) Impaired vision C) Lack of access to facilities D) Dementia Rationale: An immobilized client may experience incontinence if a call light is not within reach; a client with Alzheimer disease, along with other forms of dementia, may perceive the urge to void but be unable to interpret its meaning or respond by seeking a bathroom. A client with impaired vision may not be able to find the bathroom. Minimal facilities can create problems in urinary control. Urinary tract infection is not usually related to functional incontinence.
The nurse is providing care to a client whose medication therapy for the treatment of renal calculi has failed. Based on this data, which treatment option does the nurse anticipate for this client? A) Lithotripsy B) Surgical removal C) Dietary control D) Initiation of IV fluids
A) Lithotripsy Rationale: When medication fails to dissolve stones, the preferred method of treatment is lithotripsy, which is using sound waves to crush the stones so they can be passed out of the urinary system. Depending on the location of the stones, surgery may be the next step in the treatment process. Diet and fluids are used to prevent further stone formation.
The nurse is providing care to a client who is experiencing constipation. The healthcare provider prescribes Metamucil, a bulk-forming laxative. Which is a nursing consideration when administering this medication to the client? A) Offering sufficient water B) Administering rectally C) Using to treat acute constipation D) Assessing for tardive dyskinesia
A) Offering sufficient water Rationale: It is imperative that the client take Metamucil with a sufficient amount of water for the medication to be effective. Metamucil is an oral medication, and it is not typically for use in the treatment of acute constipation, as results from the medication are not immediate. Prokinetic drugs such as Reglan may cause tardive dyskinesia. Metamucil is not associated with the cause of tardive dyskinesia.
The charge nurse is observing a newly licensed nurse conduct an abdominal assessment on a client admitted with an abdominal mass that is affecting bowel elimination. Which actions by the newly licensed nurse would require the charge nurse to intervene? Select all that apply. A) Performing palpation before auscultation B) Performing auscultation before palpation C) Using inspection, auscultation, percussion, and palpation during the abdominal assessment of the client D) Using only inspection, percussion, and palpation during the abdominal assessment of the client E) Using deep palpation during the assessment process
A) Performing palpation before auscultation D) Using only inspection, percussion, and palpation during the abdominal assessment of the client E) Using deep palpation during the assessment process Rationale: Physical examination of the abdomen in relation to bowel elimination problems includes inspection, auscultation, percussion, and palpation. Auscultation should precede palpation, because palpation can alter peristalsis. Never use deep palpation on a client who has an abdominal mass, renal transplant, or polycystic kidneys, or who is at risk for hemorrhage.
A client is diagnosed with high blood pressure that is not responding to medications. The nurse suspects renal stenosis. When assessing for this condition, which location will the nurse use for auscultation? ) Renal arteries B) Bladder C) Ureters D) Internal urethral sphincter
A) Renal arteries Rationale: The nurse should auscultate the renal arteries by placing the bell of the stethoscope lightly in the areas of the renal arteries, located in the left and right upper abdominal quadrants. Systolic bruits ("whooshing" sounds) may indicate renal artery stenosis.
A client is diagnosed with benign prostatic hyperplasia (BPH). Which topics are appropriate for the nurse to include in the teaching session related to the client's condition? Select all that apply. A) Self-care B) Nutrition C) Surgical approaches to treatment D) Pharmacologic approaches to treatment E) Permanent urinary catheterization
A) Self-care B) Nutrition C) Surgical approaches to treatment D) Pharmacologic approaches to treatment Rationale: When conducting teaching for a client who is diagnosed with BPH, the nurse will include information regarding self-care, nutrition, surgical approaches for treatment, and pharmacologic approaches for treatment. Permanent urinary catheterization is not an appropriate topic to include in the teaching session.
The nurse is providing care for a client with renal calculi. Which expected outcomes will the nurse include in this client's plan of care? Select all that apply. A) The client rates pain at a 2 on a scale of 0-10 and states that a 2 is acceptable. B) The client is able to comfortably perform activities of daily living (ADLs). C) The client demonstrates a fluid intake of 800-1000mL/day. D) The client remains free of signs and symptoms of infection. E) The client chooses the appropriate diet to prevent the reoccurrence of renal calculi.
A) The client rates pain at a 2 on a scale of 0-10 and states that a 2 is acceptable. B) The client is able to comfortably perform activities of daily living (ADLs). D) The client remains free of signs and symptoms of infection. E) The client chooses the appropriate diet to prevent the reoccurrence of renal calculi. Rationale: While straining of the client's urine may indicate that the stone has passed, it is important to assess the client for possible complications. Client outcomes should include the client's rating pain at 3 or less on a 0-10 scale and being comfortable enough to perform own ADLs, the client demonstrating an adequate fluid intake of 2-3 liters a day, the client's choosing the appropriate diet to prevent the reoccurrence of renal calculi, and the client's remaining free of signs and symptoms of infection.
A client with BPH is experiencing urinary retention and bladder distention. The nurse understands that, without proper treatment, the client is at risk for complications such as diverticula, hydroureter, and hydronephrosis. Which issue related to the client's condition is most important to address in order to reduce the risk for these complications? A) The enlarging mass of prostatic tissue must be reduced. B) Straining during urination must be avoided. C) Bladder pain must be managed. D) The weak urinary stream must be strengthened.
A) The enlarging mass of prostatic tissue must be reduced. Rationale: The enlarging mass contributes to distention of the bladder, so this is the most important issue to address to avoid diverticula, hydroureter, and hydronephrosis. Straining during urination and weak stream are associated with voiding rather than urinary retention and are less critical to avoiding complications. Bladder pain is associated with storage rather than retention and should be addressed but is not critical to avoiding complications.
The nurse is providing care to a client who is experiencing urinary retention. Which diagnostic tool does the nurse anticipate will be ordered for this client? A) Ultrasonic bladder scan B) Urinalysis C) Intravenous pyelography (IVP) D) Cystoscopy
A) Ultrasonic bladder scan Rationale: An ultrasonic bladder scan is the diagnostic test that is used to examine for residual urine. A urinalysis is often used to monitor the urine for infection. An IVP is used to diagnosis a kidney stone. A cystoscopy allows direct visualization of the bladder wall and urethra. It is often used to remove stones.
A client presents to the urologist with complaints of getting up to urinate several times a night and difficulty starting a stream of urine. After medical testing is completed, a diagnosis of benign prostatic hyperplasia (BPH) is made. After conducting teaching regarding BPH, which statement by the client indicates the need for further education? A) "Alpha blockers can be used to control my symptoms." B) "I know I will get cancer of the prostate because of this." C) "As my condition progresses, I may need to consider surgical management." D) "There are nonsurgical treatment options available."
B) "I know I will get cancer of the prostate because of this." Rationale: BPH is a benign condition that is not considered a precursor to cancer. It is caused by an increase in size of the prostate gland and is seen in older males. Alpha blockers will help control the symptoms. There are nonsurgical treatments available, such as medication to shrink the gland along with surgical management, such as resection.
The nurse is reviewing information about four clients who are coming in to the office today due to concerns about bowel elimination. Which of these clients is most likely to have a daily stool softener added to their treatment regimen? A) A 3-month-old client who is exclusively breastfed B) A 43-year-old client who takes opioid medication for chronic pain C) A 92-year-old client who experiences frequent leakage of feces from the anus D) A 28-year-old client who is anemic and has blood in the stool
B) A 43-year-old client who takes opioid medication for chronic pain Rationale: Clients taking opioids have an increased risk of developing constipation and may prevent it by taking daily stool softeners. Breastfed infants typically have soft, liquid stools and would not benefit from a stool softener. Leakage of feces from the anus is indicative of bowel incontinence—not constipation—and would not be treated with a stool softener. Anemia and blood in the stool are indicators of potential bowel cancer or other serious conditions; this client would likely undergo testing rather than be prescribed a stool softener.
A nurse is caring for four clients with renal calculi. Of these clients, which one should the nurse identify as having the highest likelihood of requiring surgery to remove the calculi? A) A 7-year-old with calcium phosphate stones of the bladder B) A 78-year-old client with struvite stones of the kidney C) A 31-year-old expectant mother with calcium oxalate stones of the kidney D) A 46-year-old with uric acid stones of the bladder
B) A 78-year-old client with struvite stones of the kidney Rationale: Older individuals are less likely to pass a stone spontaneously and are more likely to require surgical intervention for stones than younger clients, so the 78-year-old client should be considered at the highest risk for surgery. Additionally, struvite stones are more often treated with surgical intervention than other types of stones. Surgery is also contraindicated in pregnant clients.
The nurse is caring for a group of clients on a medical-surgical unit. Which client does the nurse anticipate to be at the greatest risk for alterations in urinary elimination? A) The client with hypertension who takes a diuretic to manage blood pressure B) An 80-year-old male client reporting frequent urination at night C) A 25-year-old female client with low self-esteem D) A client who had bladder cancer and now has a newly created ileal conduit
B) An 80-year-old male client reporting frequent urination at night Rationale: The client who is 80 years old with frequent urination at night may be having problems with his prostate. Older male adults experience urinary retention due to prostate enlargement, causing an alteration in urinary elimination. The 25-year-old experiencing low self-esteem has a psychological problem and will need therapy to find the root of the problem. The client who had bladder cancer and now has an ileal conduit doesn't have kidney damage, only the bladder removed. Continued urine production through the ileal conduit will need to be observed and assessed frequently by the staff. The client with high blood pressure takes medication to remove excess fluid from the body, and as long as urine elimination increases, there should be no problems.
The nurse on the medical unit is admitting an older adult client whose primary symptoms include fatigue, pruritus, and pain in the right flank area. When conducting this client's assessment, which technique is the least appropriate? A) Palpation over the costovertebral angles and flanks B) Blunt percussion over the costovertebral angles and flanks C) Palpation of the lower pole of both kidneys D) Capturing of both kidneys
B) Blunt percussion over the costovertebral angles and flanks Rationale: Blunt percussion in a frail older individual is contraindicated. Instead, palpation of the costovertebral angles and flanks can be used to reveal any pain or tenderness. All other assessments are appropriate.
The nurse is triaging a client who presents to the urgent care clinic with symptoms of severe flank pain with spasms, nausea, vomiting, and oliguria. The client states that the pain was initially intermittent and radiated from the lower back to the lower quadrants of the abdomen. Which action by the nurse is the most appropriate? A) Complete the physical assessment. B) Consult a urologist immediately. C) Instruct the client to increase fluids. D) Obtain a urine specimen for culture.
B) Consult a urologist immediately. Rationale: Hydroureter is a complication that occurs when a renal calculus moves into the ureter and blocks and dilates the ureter. Symptoms include severe pain and spasms, nausea, vomiting, and diminished volume of urine. Hydroureter is a medical emergency that can lead to shock, infection, and subsequent impaired renal function; medical collaboration should be initiated immediately. All other options, while important to complete, would not be appropriate in an emergency situation.
The nurse is caring for a client with functional incontinence. Which conditions are factors in the development of this type of incontinence? Select all that apply. A) Fecal impaction B) Dementia C) Confusion D) Prostate surgery E) Impaired mobility
B) Dementia C) Confusion E) Impaired mobility Rationale: Functional incontinence occurs when the ability to respond to the need to urinate is impaired. Contributing factors may include confusion, dementia, or impaired mobility. Fecal impaction is a contributing factor to overflow incontinence and prostate surgery is a contributing factor to stress incontinence.
Which statement most accurately describes why benign prostatic hyperplasia is more common in older men than in younger men? A) An increase in androgen production occurs with age, and increased androgens trigger prostatic growth. B) Hyperplasia of stromal and epithelial cells in the prostate gland occurs over a long period of time. C) A decrease in estrogen levels occurs over time and results in an increase in the size of the individual cells within the prostate. D) Frequency of urinary tract infections increases with age, and frequent UTIs contribute to changes in the prostate.
B) Hyperplasia of stromal and epithelial cells in the prostate gland occurs over a long period of time. Rationale: Hyperplasia is an increase in the number of cells; in the case of BPH, hyperplasia occurs in the cells of the prostate over a long period of time. As men age, androgen production decreases rather than increases. Estrogen levels increase with age rather than decreasing. UTIs are often a result rather than a cause of BPH.
The nurse is providing follow-up care for a client was recently diagnosed with benign prostatic hyperplasia (BPH). Which nursing diagnosis is the priority for the nurse to include in the client's plan of care? A) Chronic Pain B) Impaired Urinary Elimination C) Constipation D) Diarrhea
B) Impaired Urinary Elimination Rationale: The priority diagnosis for a client diagnoses with BPH is Impaired Urinary Elimination. Acute pain, not chronic pain, is also an appropriate diagnosis. Clients with BPH have problems associated with urinary elimination, not bowel elimination. Constipation and Diarrhea are not appropriate nursing diagnoses for this client.
The nurse is providing care to a client in the healthcare clinic. The client's brother was recently diagnosed with benign prostatic hyperplasia (BPH), and the client wants to know if he is also at risk. Which item in the client's history increases the risk for BPH? A) Decreased levels of progesterone B) Increased levels of estrogen C) 35 years of age D) Testicle removal due to cancer
B) Increased levels of estrogen Rationale: Clients with increased levels of estrogen are at an increased risk for developing BPH. Clients younger than 40 years of age are at a decreased risk for BPH. Having testicles removed prior to puberty due to cancer also decreases the risk of BPH.
The nurse is caring for a client who will be discharged with an indwelling catheter. The nurse has provided education to the client and family in regard to catheter care once the client is discharged. Which client or family action indicates a correct understanding of the information presented? A) Hanging the drainage bag on a towel rod B) Taking a shower each day instead of taking a tub bath C) Restricting the amounts of fluids per day D) Emptying the drainage bag twice a day
B) Taking a shower each day instead of taking a tub bath Rationale: The client should take a shower rather than a tub bath because sitting in a tub allows bacteria to easily access the urinary tract. The drainage bag should be emptied regularly, not just once a day but at least three times a day. Hanging the drainage bag on the towel rod is too high. The drainage bag should be hung below the bladder. Adequate amounts of fluids should be consumed to help prevent sediments and infections.
The nurse is providing care to a client who is diagnosed with mild benign prostatic hyperplasia (BPH) who is experiencing urinary retention. Which goal is the most appropriate for this client? A) The client will increase fluid intake to at least 2-3 liters daily. B) The client lists over-the-counter medications to be avoided. C) The client will voice an understanding of the importance of the use of antiembolic stockings and compression devices. D) The client will use a T-binder or scrotal support properly.
B) The client lists over-the-counter medications to be avoided. Rationale: Avoiding over-the-counter medications can lessen or prevent the symptoms associated with mild benign prostatic hyperplasia (BPH). An increased fluid intake can assist in preventing burning on urination after catheter removal and reduces the risk of a urinary tract infection. There is no indication that this client had surgery or had a catheter placed. The use of antiembolic stockings and compression devices reduces the risk of developing a thromboembolism. There is no indication that this client had surgery or is at risk for developing a thromboembolism. The use of a T-binder or scrotal support is for those clients that have undergone surgery and are in need of scrotal support and support of the surgical dressing. There is no indication that this client had surgery or had a catheter placed.
The nurse is providing care to a client who is diagnosed with stress incontinence. Which data would nurse expect to collect during the client's health history and physical assessment? Select all that apply. A) Urine leakage while talking B) Urine leakage while coughing C) Urine leakage while laughing D) Skin breakdown on the buttock E) A urinary catheter
B) Urine leakage while coughing C) Urine leakage while laughing D) Skin breakdown on the buttock Rationale: Stress incontinence involves a small leakage of urine when a client laughs, coughs, or lifts something heavy, not if a client just carries on a conversation. A client with incontinence would wear some kind of undergarment pad; a urinary catheter is not an expected finding. If the client has been experiencing incontinence, the nurse might expect to see the skin inflamed and irritated because urine is very irritating to the skin.
The nurse is caring for an older adult client on a medical-surgical unit. The client tells the nurse, "I don't get any sleep at night because I have to get up and use the bathroom every couple of hours!" When providing an explanation for the nocturia, which statement by the nurse is the most appropriate? A) "As you get older, there is a decrease in number of nephrons." B) "As you get older, there is a decrease in the blood supply to your bladder." C) "As you get older, you may have a decreased bladder capacity." D) "As you get older, there is a decrease in cardiac output, causing these symptoms."
C) "As you get older, you may have a decreased bladder capacity." Rationale: Approximately 70% of older women and 50% of older men have to get up two or more times during the night to empty their bladders due to decreased bladder capacity. A decrease in blood supply causes an increase in urine concentration. A decrease in the number of nephrons decreases the filtration rate. A decrease in cardiac output decreases peripheral circulation, which would decrease urinary output day or night.
The nurse is preparing to discharge a client with diarrhea. The healthcare provider prescribes loperamide to manage the client's diarrhea. After providing the client with information on this medication, which client statement indicates the need for further education? A) "If my diarrhea does not get better within 2 days, I will need to call my healthcare provider for further advice." B) "I will need to take the medication after each loose stool." C) "I should continue to take this medication daily until my stools are firm and dry." D) "If I start to have a fever, I need to contact my healthcare provider about continuing to take this medication."
C) "I should continue to take this medication daily until my stools are firm and dry." Rationale: Continuing to take the medication daily until the stools are firm and dry could result in constipation. If constipation occurs, the client will have another issue for resolution. The other statements are correct.
The nurse is providing care to a client who ignores the urge to defecate when at work. The client states, "I don't like to have a bowel movement anywhere but at home." Which response by the nurse is the most appropriate? A) "This is a common practice, and it will strengthen the reflex later." B) "You will get the urge later, so you should not worry about it." C) "If you continue to ignore the urge to defecate, it can lead to problems." D) "It is better to suppress the urge than to suffer embarrassment at work."
C) "If you continue to ignore the urge to defecate, it can lead to problems." Rationale: When the normal defecation reflexes are inhibited, these conditioned reflexes tend to be progressively weakened. When the urge to defecate is ignored, water continues to be reabsorbed, making the feces hard and difficult to expel. Ignoring the urge repeatedly will eventually cause the urge to be lost. Embarrassment, while unwarranted, is preferable to losing the urge to defecate. Ignoring the urge will not strengthen the reflex later; it will weaken it.
The nurse is caring for a middle-aged male client who is experiencing urinary retention. The client asks the nurse if it is possible that he is experiencing benign prostatic hyperplasia (BPH). During the client history, the client reports that he is of Japanese descent. Which response by the nurse is the most appropriate? A) "No, you are not old enough to have BPH." B) "Your symptoms are not consistent with BPH." C) "You are considered low-risk for BPH." D) "Where did you get an idea that you might have BPH?"
C) "You are considered low-risk for BPH." Rationale: The nurse must always provide honest responses to client questions. The nurse should tell the client that due to his ethnicity, he is considered low-risk for developing BPH. While age does increase the risk of BPH, it is not the only factor to consider. The client is experiencing urinary retention, which is consistent with BPH. Asking a client where he got that idea is demeaning.
The nurse is providing care to a client who is diagnosed with benign prostatic hyperplasia (BPH). The client's primary concern is burning and difficulty when urinating. Based on this data, which nursing diagnosis is the priority for this client? A) Fluid Volume Overload B) Fluid Volume Deficit C) Acute Pain D) Deficient Knowledge
C) Acute Pain Rationale: The client is experiencing burning and other difficulties during urination. The burning indicates the client is experiencing pain and would indicate a priority nursing diagnosis of acute pain. There is no evidence of fluid volume overload, fluid volume deficit, or knowledge deficit.
Urge incontinence is the involuntary loss of urine associated with a strong urge to void and an increased rate of urination. Which condition can contribute to urge incontinence? A) Weakness of the urethra and surrounding tissue leading to decreased urethral resistance B) Disruption to neuronal control of the sacral micturition centers due to tissue damage C) An overactive detrusor muscle leading to increased pressure within the bladder D) Outlet obstruction leading to the overfilling of the bladder and increased pressure
C) An overactive detrusor muscle leading to increased pressure within the bladder Rationale: An overactive detrusor muscle leading to increased pressure within the bladder is a contributor to urge incontinence. Weakness of the urethra and surrounding tissue leading to decreased urethral resistance is a contributor to stress incontinence. Disruption to neuronal control of the sacral micturition centers due to tissue damage is a contributor to reflex incontinence. Outlet obstruction leading to the overfilling of the bladder and increased pressure is a contributor to overflow incontinence.
The nurse is caring for an older adult client. The client tells the nurse that he is constipated. What is the nurse's initial action? A) Encourage the client to increase fluid intake and activity. B) Assess the client's intake of fiber and fluids. C) Determine what the client means by constipation. D) Obtain an order for a laxative and an enema from the physician.
C) Determine what the client means by constipation. Rationale: Many older adults believe that a daily bowel movement is important for health, which leads to an increased incidence of perceived constipation in older adults. The nurse should first carefully evaluate the client's concern and question the person as to what is meant by constipation. Determining the client's normal frequency of bowel movement, consistency of stool, and effort in passing stool is important before deciding to act. The other suggestions—achieving adequate fluid intake, exercising, including fiber in the diet, and using a laxative (and possibly an enema)—may be appropriate once the nurse has adequately assessed the client's concern of constipation.
Clients experiencing diarrhea often lose electrolytes. Which of the following best describes the reason for this loss? A) Decreased secretion of intestinal mucus inhibits the absorption of electrolytes from the chyme by the intestine. B) Pathogenic microorganisms that cause diarrhea consume the electrolytes in the chyme, resulting in fewer electrolytes being available for absorption. C) Diarrhea causes rapid passage of chyme through the large intestine, reducing the time available for absorption of electrolytes. D) Intestinal bacteria break down electrolytes during diarrhea and make them unfit for absorption by the intestine.
C) Diarrhea causes rapid passage of chyme through the large intestine, reducing the time available for absorption of electrolytes. Rationale: Diarrhea causes rapid passage of chyme through the large intestine. This reduces the time available for the large intestine to absorb electrolytes and results in the electrolytes being lost with feces. Diarrhea typically increases secretion of intestinal mucus rather than decreasing it. Pathogenic microorganisms result in inflammation of the mucosa. Bacteria in the intestine cannot break down electrolytes.
A client is admitted to the emergency department and diagnosed with renal colic after experiencing symptoms for 1 week, including those associated with the body's sympathetic response to severe pain. When planning care for this client, which nursing diagnosis is the most appropriate? A) Risk for Constipation B) Risk for Disuse Syndrome C) Imbalanced Nutrition D) Activity Intolerance
C) Imbalanced Nutrition Rationale: The client with renal colic of lengthy duration is at risk for imbalanced nutrition from the resulting nausea. Activity intolerance, risk for constipation, and risk for disuse syndrome are not as appropriate because the symptoms of urinary calculi do not lead to these diagnoses.
The nurse is caring for a client with a history of chronic urinary tract infections. The nurse is planning care for this client based on the priority nursing diagnosis of urinary retention related to scarring. Based on this data, which treatment does the nurse anticipate from the healthcare provider? A) Antibiotic therapy B) An anticholinergic medication C) Intermittent straight catheterization D) Removal of bladder stones
C) Intermittent straight catheterization Rationale: The healthcare provider may order straight catheterization so the client can be taught to self-catheterize and manage the urinary retention at home. Antibiotic therapy is not indicated, as the client does not have an infection now. Anticholinergic medications can cause urinary retention. Bladder stones are not the problem; scarring is.
The client is experiencing urinary urgency and frequency. Which medication should the nurse anticipate may be prescribed by the healthcare provider? A) Furosemide B) Bumetanide C) Oxybutynin D) Bethanechol chloride
C) Oxybutynin Rationale: Oxybutynin is an anticholinergic that reduces urgency and frequency by blocking muscarinic receptors in the detrusor muscle of the bladder, thereby inhibiting contractions and increasing storage capacity. The nurse would anticipate an order for oxybutynin. Furosemide is a diuretic and works in a specific place within the nephron to increase fluid excretion and prevent fluid reabsorption. Bumetanide is a diuretic and works in a specific place within the nephron to increase fluid excretion and prevent fluid reabsorption. Bethanechol chloride is a cholinergic agent that stimulates bladder contraction and facilitates voiding.
The nurse is assigned to a postpartum client who had an anesthetic block during labor and delivery. When providing care for this client, which does the nurse anticipate? A) Nocturnal enuresis B) Risk for hyperkalemia C) Residual urine D) Glycosuria
C) Residual urine Rationale: The postpartum woman is at risk for overdistention, incomplete bladder emptying, and buildup of residual urine (urine that remains in the bladder after voiding). Glycosuria is expected for a client during pregnancy, not during the postpartum period. Nocturnal enuresis and risk for hyperkalemia are anticipated for older adult clients.
A client is recovering from prostate surgery on a medical-surgical unit. The client will be ready for discharge within the next few days. Which teaching point is appropriate for this client? A) The client should not drive for 6 weeks after surgery. B) The client should call the healthcare provider immediately for any bleeding. C) The client should incorporate fruit juice in his diet. D) The client should avoid heavy lifting for 2 weeks after surgery.
C) The client should incorporate fruit juice in his diet. Rationale: The client should be encouraged to incorporate fruit juice in his diet to help keep bowel movements regular and soft, as straining for bowel movements after surgery can cause increased pressure in the prostate area. The client may not drive for 2 weeks after surgery. The client is taught to avoid heavy lifting for 4-8 weeks after discharge and to call the doctor for heavy bleeding, though minor bleeding when defecating, coughing, or exercising is normal.
A client with urinary calculi is admitted to the hospital. When planning care for this client, which goal is most appropriate? A) The client will lose 25 pounds in 3 months. B) The client will ambulate three times a day. C) The client will request pain medication at the onset of pain. D) The client will shower independently.
C) The client will request pain medication at the onset of pain. Rationale: Intense pain is the hallmark of urinary calculi, or kidney stones, that are passing through the urinary system. The nurse teaches the client to request pain medication at the onset of pain in order to provide faster relief. The client with urinary calculi is able to ambulate and shower independently. Dietary changes will need to be made to prevent further formation of stones, but weight loss is not necessarily a goal with this disease process.
The nurse is providing care to a client who is diagnosed with mild benign prostatic hyperplasia (BPH). Which lifestyle change is appropriate for this client? A) Increasing caffeine intake B) Increasing alcohol intake C) Urinating at first urge D) Using over-the-counter antihistamines
C) Urinating at first urge Rationale: A client who is diagnosed with mild BPH is often treated with lifestyle changes and a "watchful waiting" approach. Urinating at first urge is a lifestyle change that is appropriate for this client. The client should also eliminate caffeine and alcohol from the diet. It is also important for this client to avoid using over-the-counter antihistamines.
The nurse is providing care to a client at a local clinic. The nurse suspects that the client is experiencing a urinary tract infection. Which urinalysis result supports the nurse's suspicions? A) pH 5.2 B) Negative glucose C) WBC 10-15 D) Specific gravity 1.012
C) WBC 10-15 Rationale: A urinalysis typically consists of the pH, glucose, specific gravity, protein, and WBC count. The pH, glucose, and specific gravity are all within normal limits. A normal WBC is 3-4. The WBC count for this client is high and indicates infection.
The nurse is reviewing discharge instructions for a client diagnosed with urinary incontinence resulting from a urinary tract infection. Which statement made by the client indicates the need for further education? A) "I should drink plenty of water to prevent damage to my kidneys while I am on the antibiotics for the infection." B) "Drinking cranberry juice will decrease the risk for developing urinary tract infections." C) "I will contact the healthcare provider prior to taking over-the-counter medications while on my antibiotic." D) "I will continue to hold my urine while in public so that I do not get another infection."
D) "I will continue to hold my urine while in public so that I do not get another infection." Rationale: A client who is diagnosed with urinary incontinence secondary to a urinary tract infection will require specific education. The client who states that he or she will hold their urine while in public to decrease the risk of another infection requires more education. Urinary retention is a contributing factor to urinary tract infections. The other statements are appropriate and indicate appropriate understanding of the information presented.
A nurse is caring for a client with congestive heart failure. The healthcare provider prescribes propranolol (Inderal) for the client. Which instruction should the nurse include when administering a beta-adrenergic like propranolol (Inderal) to the client? A) "This medication must be taken on an empty stomach." B) "You will need to discontinue the medication when your symptoms subside." C) "This medication causes constipation. You should take a laxative every day." D) "It is important to notify the healthcare provider if you experience urinary retention."
D) "It is important to notify the healthcare provider if you experience urinary retention." Rationale: A beta-adrenergic blocker such as propranolol can cause urinary retention; therefore, it would be important for the client to notify the healthcare provider if this occurs. Clients should always check with their healthcare provider before stopping any medication, because there could be some major complications. Constipation has been reported from clients taking propranolol, but a laxative should not be taken every day, as one can become dependent. This medicine should be taken with food, not on an empty stomach, in order to enhance absorption.
The nurse is interviewing a client who is experiencing constipation. During the interview, the client states, "I don't understand what is going on. I feel the urge to go to the bathroom but, once I am in there and I begin pushing with my abdominal muscles, nothing happens." Which of the following represents the nurse's best response to the client? A) "Try taking an over-the-counter medication containing bismuth salts, such as Kaopectate or Pepto-Bismol. If your symptoms don't subside in 2 days, come back to the office." B) "Stop taking all medications until you have reestablished a normal elimination routine. Medication usage often leads to constipation." C) "Make sure that you are taking proper care of the skin in the anal area. Skin breakdown can result in hesitancy when defecating." D) "Try to avoid straining with the abdominal muscles during defecation. Doing so may actually close the anal sphincter, preventing feces from passing through."
D) "Try to avoid straining with the abdominal muscles during defecation. Doing so may actually close the anal sphincter, preventing feces from passing through." Rationale: Clients should be instructed to use caution when straining the abdominal muscles during defecation, because it may close the anal sphincter rather than allowing feces to pass through. Bismuth salts are antidiarrheals-not laxatives-and would likely compound the client's problem. Certain medications can lead to constipation in some clients, but it is not appropriate for the nurse to encourage the discontinuation of all medications. Skin care is a concern for clients who are experiencing diarrhea or fecal incontinence, and is not typically an issue for patients with constipation.
The nurse is preparing to discharge a client who underwent lithotripsy for the treatment of a kidney stone. What should the nurse teach the client to prevent further complications of urinary calculi after discharge? A) "You will need to increase your oral fluid intake to 1 L/day." B) "It will be important that you not drive while taking pain medications." C) "It will be important to maintain a diet high in purines." D) "You will need to monitor for the signs and symptoms of a urinary tract infection (UTI)."
D) "You will need to monitor for the signs and symptoms of a urinary tract infection (UTI)." Rationale: The client with stones may develop a UTI when formed stones obstruct urinary flow. These symptoms should be reported as early as possible to the primary care provider. By discharge, the stones should have passed and there would be no need for pain medication. Fluid intake per day should be 2.5-3.0 L. Foods high in purines, such as organ meats, are to be avoided.
The nurse is caring for a client with a history of kidney stones. The stones have been analyzed and are all composed of calcium phosphate. Based on this data, which foods should the nurse teach the client to avoid? A) Chicken, beef, and ham products B) Organ meats, sardines, and seafood C) Tomatoes, fruits, and nuts D) Flour, milk, and ice cream
D) Flour, milk, and ice cream Rationale: Flour, milk, and milk products such as ice cream have high calcium levels and, therefore, are recommended to be reduced to decrease the risk of further episodes of calcium-containing calculi. Organ meats, sardines, seafood, tomatoes, fruits, nuts, chicken, beef, and ham products are not high in calcium and do not need to be restricted for this client.
A client with a history of urinary calculi presents with frequency, urgency, and dysuria. A urinalysis reveals formation of crystals in the urine, known as nucleation. Based on this finding, which statement is true about the composition of the client's urine? A) It has a high concentration of citrate and glycoproteins. B) It has a pH of 7.0. C) It contains trace amounts of blood. D) It has a high concentration of insoluble salt.
D) It has a high concentration of insoluble salt. Rationale: High insoluble salt concentration in the urine—known as supersaturation—leads to formation of crystals in the urine. Citrate and glycoproteins are protective substances in the urine that prevent crystals from forming and would be low in urine containing crystals. A pH of 7.0 is neutral, and urine crystals tends to be either acid or alkaline. While trace amounts of blood may be in the urine, blood is not a finding consistent with crystal formation.
The nurse is conducting education regarding urinary health at an assisted living facility. When planning topics to include in the session, which are appropriate for the nurse to consider? Select all that apply. A) Full urinary control usually occurs at 4 or 5 years of age. B) Due to neuromuscular immaturity in infancy, voluntary urinary control is absent. C) The kidneys reach maximum size between 35 and 40 years of age. D) Renal blood flow decreases because of vascular changes and a decrease in cardiac output. E) Urinary incontinence may occur because of mobility problems or neurological impairments.
D) Renal blood flow decreases because of vascular changes and a decrease in cardiac output. E) Urinary incontinence may occur because of mobility problems or neurological impairments. Rationale: When planning an education session regarding urinary health at an assisted living facility, the nurse would include information that affects the urinary health of the older adult client. Information that is appropriate for the nurse to consider is the decrease in renal blood flow due to vascular changes and that urinary incontinence may occur because of issues with mobility and neurological impairment. While all of the other statements are true regarding urinary health, they are not appropriate for this presentation to older adult clients.
The nurse is providing care to a client who is experiencing urinary incontinence. Which independent nursing intervention is the most appropriate for this client? A) Encouraging increased fluid intake B) Providing catheter care C) Instructing on self-catheterization D) Teaching hygiene care
D) Teaching hygiene care Rationale: Clients with urinary incontinence must be taught hygiene care—sometimes called incontinence care—to protect against tissue breakdown. Encouraging increased fluid intake is appropriate for a client who is dehydrated. Instructing on self-catheterization and providing catheter care is appropriate for a client who is diagnosed with urinary retention.
The nurse is working in a urology clinic and is providing care for a client with stress urinary incontinence. The nurse has chosen the diagnosis of Stress Urinary Incontinence related to sphincter incompetence. Which is the desired outcome for a client with this diagnosis? A) The client will stop the flow of urine when voiding. B) The client will improve her incontinence within 1 month. C) The client will empty her bladder every time she voids. D) The client will perform 4-5 squeezes (Kegel exercises) for 10-15 seconds.
D) The client will perform 4-5 squeezes (Kegel exercises) for 10-15 seconds. Rationale: Performing 4-5 squeezes for 10-15 seconds is the goal to start with when teaching a client Kegel exercises, which are used for stress and urge incontinence. Emptying the bladder completely every time she voids would not be realistic in the beginning. This will take time. Improved continence takes 3-6 months, so 1 month is not a realistic goal. Clients are not instructed to stop the flow of urine when voiding, because this could lead to retention.
The charge nurse is observing a newly licensed nurse catheterize an older adult client admitted with an enlarged prostate. Which action by the newly licensed nurse requires intervention from the charge nurse? A) The newly licensed nurse injects 10 mL of 2% lidocaine gel into the client's urethra. B) The newly licensed nurse inserts a 16 French coudé-tipped catheter. C) The newly licensed nurse uses sterile technique to place the catheter. D) The newly licensed nurse clamps the catheter after draining 800 mL.
D) The newly licensed nurse clamps the catheter after draining 800 mL. Rationale: Draining 800 mL before clamping might cause a vasovagal response, so the charge nurse would need to intervene. Using 2% lidocaine gel 10 mL injected into the male urethra reduces discomfort during catheterization and the risk of catheter-associated infection, and it promotes pelvic muscle relaxation. A coudé-tipped catheter is passed more easily in the older man with an enlarged prostate. Sterile technique should always be used when inserting catheters.
A client is recovering from minimally invasive surgery due to a diagnosis of benign prostatic hyperplasia (BPH). After assessing the client, the nurse expects which outcome for this client? A) Bowel continence B) Absence of pain C) No postoperative treatment D) Urinary continence
D) Urinary continence Rationale: After surgery and removal of the catheter, the client should return to urinary continence as expected. The client will need postoperative teaching and will experience some amount of discomfort. Most clients, due to pain and swelling in the area, may have problems with constipation immediately following the surgical intervention.
A client presents with acute constipation for the second time in two months. The physician orders a diagnostic barium enema. Based on the testing order, the nurse understands that the client's condition is likely associated with: A) rectal muscle contractions. B) completeness of bowel elimination. C) the efficiency with which the food moves through the gastrointestinal tract. D) the structure of the bowel or the presence of tumors or diverticula.
D) the structure of the bowel or the presence of tumors or diverticula. Rationale: A barium enema is used to identify bowel structure, tumors, or diverticula; thus, the nurse understands that one of these is likely a causative factor in the client's condition. A defecography is used to assess rectal muscle contractions. An anorectal manometry is used to assess the completeness of bowel elimination. A colorectal transit study is used to determine how efficiently food moves through the gastrointestinal tract.
