The patient confides that sneezing makes her "wet her pants." The nurse recognizes that this is a cardinal sign of ______ incontinence
a. urge
b. stress
c. functional
d. overflow
B
Stress incontinence occurs when the urethral sphincter fails and there is an increase in in-tra-abdominal pressure, caused by such things as sneezing, laughing, coughing, or aerobic exer-cise. Urge incontinence is the involuntary loss of urine when there is a strong urge to urinate (urinary urgency). Functional incontinence is caused by cognitive inability to recognize the urge to urinate or self-care deficit caused by extreme depression. Inability to reach the bathroom due to restraints, side rails, or an out-of-reach walker can also result in functional incontinence. Overflow incontinence occurs when there is poor contractility of the detrusor muscle or obstruc-tion of the urethra, as in prostate hypertrophy in the male or genital prolapse or abnormality in the female.
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The family of an older patient with Alzheimer's disease does not want to discuss long-term care placement for at least "a few years." How should the nurse respond to the family?
1. "Long-term care placement is inevitable with this diagnosis." 2. "It often takes a year for an individual with Alzheimer's disease to be admitted." 3. "Talking about it now gives you time to think about locations and make a decision." 4. "By providing this information now, we will not need to address these concerns later."
A client complains to the nurse that her daughter often shivers after she comes out of a swimming pool. Based on this information, the nurse recognizes that the client needs further teaching about the mechanisms of shivering
What should the nurse's response be? A) "This could be serious; you should consult a physician immediately." B) "This is an expected response; shivering is a body mechanism that assists temporary regulation." C) "This may be risky; your daughter should avoid swimming completely." D) "Your daughter should have a hot water bath as soon as she comes out of the pool."
The student nurse is preparing to auscultate the client's lungs during the initial assessment. Which student nurse statement to the nurse preceptor indicates the need for further education prior to conducting the assessment?
1. "I should think about how loud the auscultated sound is, the tone of the sound, and how long it lasts." 2. "I should leave the client's television on during the assessment to make the client feel relaxed and comfortable during the assessment." 3. "I have to remember to keep the client warm during this part of the assessment." 4. "I cannot listen through the client's gown."
When teaching the client about proper condom use, which of the following should the nurse include? (Select all that apply.)
a. is just as effective as other birth control methods b. should be discarded after two ejaculations c. disposal includes by holding at the base of the penis after ejaculation d. can be used to prevent oral-genital membrane contact e. store in a cool, dry place away from sunlight f. provides the most protection against sexually transmitted infections (STIs)