An emergency department nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question should the nurse ask first?
a. "Are you drinking plenty of water?"
b. "What medications are you taking?"
c. "Have you tried laxatives or enemas?"
d. "Has this type of thing ever happened before?"
ANS: B
Some types of incontinence are treated with anticholinergic medications such as propantheline (Pro-Banthine). Anticholinergic side effects include dry mouth, constipation, and urinary retention. The nurse needs to assess the client's medication list to determine whether the client is taking an anticholinergic medication. If he or she is taking anticholinergics, the nurse should further assess the client's manifestations to determine if they are related to a simple side effect or an overdose. The other questions are not as helpful to understanding the current situation.
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