Deck 16: Elimination

Question 1

An otherwise healthy older adult reports having begun to experience problems "holding my water." The nurse shows an understanding of interventions that may help minimize the problem of urinary incontinency when: (Select all that apply.)

A) asking whether the client smokes tobacco.
B) assessing the average amount of caffeine the client drinks daily.
C) asking if the client has been evaluated for diabetes recently.
D) suggesting the client keep a record of the amount of fluids ingested daily.
E) reviewing the client's current medication list.

Answer 1

asking whether the client smokes tobacco.
assessing the average amount of caffeine the client drinks daily.
asking if the client has been evaluated for diabetes recently.
reviewing the client's current medication list.

Question 2

A nurse caring for a cognitively impaired older adult client shows an understanding of the unique clinical symptoms of constipation in this population when: (Select all that apply.)

A) checking documentation to determine if the client has had a bowel movement in the last 24-36 hours.
B) questioning staff as to whether the client has any unexplained falls in the last few days.
C) asking the client to name all of his or her children and grandchildren.
D) requesting that the client's temperature be taken now and again in 4 hours.
E) reviewing the client's food intake over the last 24-36 hours.

Answer 2

questioning staff as to whether the client has any unexplained falls in the last few days.
asking the client to name all of his or her children and grandchildren.
requesting that the client's temperature be taken now and again in 4 hours.
reviewing the client's food intake over the last 24-36 hours.

Question 3

A nurse is caring for an older adult in a hospital who has an indwelling catheter. The nurse assesses the patient based on the knowledge that which of the following are correct indications for an indwelling catheter? (Select all that apply.)

A) To assist with incontinence management
B) To manage acute urinary retention
C) To assist in healing of open sacral or perineal wounds in incontinent patients
D) To accurately measure urinary output in critically ill patients
E) To prevent falls related to toileting in hospitalized older patients

Answer 3

To manage acute urinary retention
To assist in healing of open sacral or perineal wounds in incontinent patients
To accurately measure urinary output in critically ill patients

Question 4

An 89-year-old hospitalized female patient tells a nurse, "I go to the bathroom really often, but I manage this by not drinking too much before I go to bed so I can sleep for the night." The patient has no pain or discomfort with voiding. The nurse considers this finding to be a:

A) manifestation of urge incontinence.
B) manifestation of a urinary tract infection.
C) normal age-related change in an 89-year-old woman.
D) manifestation of diabetes.

Question 5

A nurse implements a nursing care plan for a patient with constipation. Which of the following should the nurse include in the plan?

A) Increasing fiber in the diet
B) Administering aluminum hydroxide antacids
C) Bed rest
D) Restricting fluids

Question 6

The nurse interviewing an older adult for a nursing history recognizes that the client is experiencing symptomology inconsistent with normal aging of the urinary tract when the client reports: (Select all that apply.)

A) finding it more difficult in the last few months to start voiding.
B) having two bladder infections in the last 4 years.
C) getting up once or twice each night to urinate.
D) occasionally experiencing pain when urinating.
E) needing to urinate at least every 2 hours during the day.

Question 7

A 74-year-old woman who is in the hospital for rehabilitation following hip replacement has been experiencing incontinence since admission. Which of the following interventions are likely to facilitate the restoration of the patient's bladder function? (Select all that apply.)

A) Assess the patient's recent voiding pattern.
B) Request an order for an indwelling catheter from the patient's physician.
C) Teach the patient how to meet hydration needs while still limiting fluid intake.
D) Assist the patient to use the bathroom.
E) Request an order for medication to decrease bladder spasms.

Question 8

A 78-year-old patient has a history of osteoarthritis and lives alone in a two-story home. The bathroom is on the first level and the bedroom is on the second level. The patient states, "I am so upset. I have been wetting the bed at night." What type of incontinence does the patient most likely have?

A) Mixed incontinence
B) Stress incontinence
C) Urge incontinence
D) Functional incontinence

Question 9

Which of the following nursing actions would help minimize the psychosocial impact of bladder and/or bowel incontinence for individuals experiencing incontinence prior to going to a group dining room?

A) Assess for soiled clothing and change, if necessary.
B) Toilet the client and then promptly transport to the dining room.
C) Provide peri-care and fresh underclothing.
D) Ask the client if toileting is needed and assist as necessary.

Question 10

A patient tells the nurse, "Every time I laugh or cough, I wet myself." Which type of urinary incontinence is this patient describing?

A) Urge
B) Functional
C) Stress
D) Mixed