NURS 120--Exam 3 (Modules 9 & 10)
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 - answerB, C, D
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." -
answerC
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 - answerB
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. - answerD
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 - answerC
The nurse is assessing an adult client in an 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." - answerA
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 - answerA, B, C, D
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 - answerB, C, E
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."
- answerD
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. - answerD
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 - answerA
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 -
answerC
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." - answerC
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." -
answerC
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. - answerC
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 - answerB, C, D
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." -
answerC
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 - answerB
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. - answerD
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 - answerC
The nurse is assessing an adult client in an 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." - answerA
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 - answerA, B, C, D
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 - answerB, C, E
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."
- answerD
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. - answerD
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 - answerA
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 -
answerC
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." - answerC
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." -
answerC
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. - answerC
