Chapter 23: Incontinence Nursing School Test Banks

Chapter 23: Incontinence
Linton: Introduction to Medical-Surgical Nursing, 6th Edition

MULTIPLE CHOICE

1. What instruction should a nurse provide to a patient scheduled for a postvoid residual (PVR) test?
a. Call the nurse immediately after voiding.
b. After voiding, wait 10 minutes and void again.
c. Void into a flow meter.
d. Avoid fluid intake for 8 hours before the test.
ANS: A
The nurse must catheterize the patient immediately after voiding and measure the amount of urine.

DIF: Cognitive Level: Application REF: p. 349 OBJ: 1
TOP: Postvoid Residual Test KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

2. Bladder training instructions are being given to a patient who has a history of urinary incontinence. What initial instructions should the nurse give to the patient?
a. Wait until you feel the urge to void.
b. Dont void any more often than every 4 to 6 hours.
c. Void every 2 to 3 hours while awake.
d. Void any time you feel the urge.
ANS: C
Bladder training uses scheduled voiding; the patient is encouraged to delay voiding and void only every 2 to 3 hours while awake.

DIF: Cognitive Level: Application REF: p. 349 OBJ: 1
TOP: Bladder Training KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. A patient with a spinal cord injury has recently begun using reflex training to empty his bladder. The nurse is doing a catheterization to check for residual volume. What should the residual volume be to indicate reflex training is effective?
a. Less than 100 mL
b. Less than 200 mL
c. Less than 400 mL
d. Less than 500 mL
ANS: A
Ideally, the residual volume will be less than 100 mL.

DIF: Cognitive Level: Comprehension REF: p. 350 OBJ: 1
TOP: Reflex Training KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. A male patient with urinary incontinence has been using an external (condom) catheter. A nurse is assessing the patients technique of applying the device. What techniques demonstrated by the patient would indicate the need for further instruction?
a. Washes the penis with warm soapy water and dries the area well before applying the device
b. Encircles the penis with tape to secure the device
c. Uses elastic tape and wraps in a spiral pattern to secure the device
d. Carefully assesses the penis for any signs of irritation before applying the device
ANS: B
Encircling the penis with tape can restrict circulation and cause damage to the tissue.

DIF: Cognitive Level: Application REF: p. 350 OBJ: 1
TOP: External Urine Collection Device KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

5. A patient being assessed by the physician states, I wet my pants every time I cough. The nurse recognizes this as which type of incontinence?
a. Reflex
b. Overflow
c. Urge
d. Stress
ANS: D
Stress incontinence is the involuntary loss of small amounts of urine during physical activity that increases abdominal pressure, such as coughing, laughing, sneezing, and lifting.

DIF: Cognitive Level: Knowledge REF: p. 354-355 OBJ: 3
TOP: Stress Incontinence KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. What instruction should a nurse provide to a patient who has been diagnosed with stress incontinence?
a. Restrict fluid intake to less than 1000 mL/day.
b. Avoid fluids such as tea, coffee, and cola.
c. Delay voiding until you feel the urge to void.
d. Void no more often than every 4 hours.
ANS: B
Fluids such as tea, coffee, and cola have a diuretic effect and should be avoided.

DIF: Cognitive Level: Application REF: p. 354 OBJ: 3
TOP: Stress Incontinence KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. A home health nurse is performing an evaluation of the home of an older adult patient to assess for any safety issues. What should the nurse recognize as an environmental factor that could lead to functional incontinence?
a. Night light in the bathroom
b. Patients room located on the opposite end of the house from the bathroom
c. Hand rails located around the toilet and bathtub
d. Caregivers room located close to the patients room
ANS: B
Functional incontinence is the term used when a person voids inappropriately because of an inability to get to the toilet or manage the mechanics of toileting. The patients room should be located close to the bathroom.

DIF: Cognitive Level: Comprehension REF: p. 357 OBJ: 1
TOP: Functional Incontinence KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. What should a nurse specifically ask a patient when taking the medical history to reveal clues to the potential cause of urinary incontinence?
a. Diabetes mellitus
b. Impetigo
c. Hypotension
d. Trigeminal neuralgia
ANS: A
Patients who have diabetes may develop neurologic problems that affect the bladder and are uncontrolled; they may produce large volumes of urine.

DIF: Cognitive Level: Comprehension REF: p. 357 OBJ: 4
TOP: Medical History KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

9. A patient, talking to a home health nurse about urinary incontinence, gives the nurse a list of the current medications she is taking. What medication should the nurse recognize as possibly contributing to the patients urinary incontinence?
a. Methylcellulose (Citrucel)
b. Diazepam (Valium)
c. Simvastatin (Zocor)
d. Digoxin (Lanoxin)
ANS: B
Valium is a sedative that can increase the incidence of incontinency of urine.

DIF: Cognitive Level: Comprehension REF: p. 357 OBJ: 4
TOP: Urinary Incontinence KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

10. A nurse is instructing a patient on the procedure for a clean-catch urine specimen. The patient has tried several times but is having difficulty understanding the instructions. What is the best action for the nurse to implement?
a. Take whatever specimen the patient can obtain.
b. Provide the patient with a clean bedpan to obtain the specimen.
c. Ask the laboratory personnel to come and obtain a urine specimen.
d. Call the physician for a catheterization order.
ANS: D
If the patient cannot cooperate with the clean-catch procedure, catheterization may be necessary.

DIF: Cognitive Level: Application REF: p. 348 OBJ: 4
TOP: Clean-Catch Urine Specimen KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

11. A patient who is scheduled for an urodynamic test asks the nurse why he is having this test. What is the nurses best response?
a. To test the capacity of the bladder.
b. To see how much urine is left in the bladder after you have voided.
c. To test the function of the nerves and muscles of the bladder.
d. To detect involuntary passage of urine.
ANS: C
Urodynamic procedures assess the neuromuscular function of the lower urinary tract.

DIF: Cognitive Level: Comprehension REF: p. 348 OBJ: 4
TOP: Urodynamic Test KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

12. A nurse has just received a patient who had a cystoscopy from the postanesthesia recovery unit. The nurse notices that the patients urine is tinged with pink. What is the first action the nurse should implement?
a. Call the physician.
b. Record the assessment in the patients record.
c. Encourage the patient to drink plenty of fluids.
d. Prepare the patient for a return to surgery.
ANS: C
Pink-tinged urine is normal at first. Encouraging fluids will help flush the patients bladder, and then the nurse should document both the assessment and implementation.

DIF: Cognitive Level: Application REF: p. 348 OBJ: 1
TOP: Cystoscopy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

13. A nurse is asked to instruct a patient on performing Kegel exercises. The patient should be instructed to contract the muscles normally used to stop the flow of urine. Which proper technique should the nurse explain?
a. Contract for 3 to 4 seconds and relax for 10 seconds.
b. Contract for 10 seconds and relax for 10 seconds.
c. Contract for 10 seconds and relax for 3 to 4 seconds.
d. Contract for 3 to 4 seconds and relax for 3 to 4 seconds.
ANS: B
The patient should hold the contraction for 10 seconds and then relax for 10 seconds. The goal is to work up to 10 repetitions three or four times each day.

DIF: Cognitive Level: Application REF: p. 350 OBJ: 1
TOP: Kegel Exercises KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. A patient who uses a pessary to help control incontinence is given instruction for its care. What should these instructions include?
a. Remove periodically for cleaning.
b. Douche daily with a cleansing solution.
c. Check for proper placement once a month.
d. Periodically deflate the cuff.
ANS: A
A pessary is a device that is inserted into the vagina to hold the pelvic organs in place. The device must be removed periodically for cleaning and replaced as needed.

DIF: Cognitive Level: Comprehension REF: p. 353 OBJ: 1
TOP: Pessary KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

15. A patient who has urinary incontinence is at risk for urinary tract infection and urinary calculi. What should the nurse teach the patient and family regarding the best way to prevent these complications?
a. Restrict the patients fluid intake and frequency of incontinence.
b. Be sure the patients voiding schedule is no more often than every 4 hours.
c. Use an indwelling catheter.
d. Encourage the patient to void at least every 2 hours and to take at least 2000 mL of fluid daily.
ANS: D
The risk of urinary tract infection and calculi can be reduced by having the patient empty the bladder as scheduled and providing adequate fluids.

DIF: Cognitive Level: Application REF: p. 361 OBJ: 4
TOP: Urinary Tract Infection and Calculi
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. A patient is having problems with fecal incontinence. What should the nurse encourage the patient to include in the diet to help with this problem?
a. Raw fruits and vegetables
b. Potatoes and bread
c. Coffee and tea
d. Prune and grape juice
ANS: B
Foods that thicken the stool, such as potatoes, bread, bananas, rice, cheese, yogurt, oatmeal, oat bran, boiled milk, and pasta, should be encouraged.

DIF: Cognitive Level: Application REF: p. 363 OBJ: 5
TOP: Dietary Changes KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. What should a nurse include as an essential factor when providing patient education about managing fecal overflow incontinence?
a. Daily use of mineral oil
b. Regular evacuation
c. Daily administration of enemas
d. Long-term use of mineral oil
ANS: B
Initially, the colon needs to be cleansed, and then regular evacuation is essential.

DIF: Cognitive Level: Application REF: p. 363 OBJ: 1
TOP: Fecal Overflow Incontinence KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. A patient tells a nurse that his bowel movements normally occur every morning after breakfast. What should the nurse understand as the rationale for this occurrence?
a. Fecal overflow
b. Gastrocolic reflex
c. Autonomic dysreflexia
d. Lack of sphincter control
ANS: B
When food enters the stomach, it stimulates activity throughout the digestive tract and causes the movement of fecal mass into the rectum.

DIF: Cognitive Level: Comprehension REF: p. 363 OBJ: 5
TOP: Gastrocolic Reflex KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

19. A physicians admission report states that a patient has a history of tarry stools. What should the nurse anticipate when assessing characteristics of this patients stool?
a. Brown and formed
b. Bright red and liquid
c. Black and sticky
d. Clay colored and pasty
ANS: C
Tarry is used to describe stools that are shiny, sticky, and black, which is usually an indication of blood in the stool.

DIF: Cognitive Level: Knowledge REF: p. 364 OBJ: 4
TOP: Characteristics of Stool KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. What education should a nurse provide to a patient diagnosed with anorectal incontinence?
a. Take a daily laxative.
b. Increase fiber in the diet.
c. Perform pelvic muscle exercises.
d. Administer daily enemas.
ANS: C
Anorectal incontinence is associated with nerve damage that causes the muscles of the pelvic floor to be weak. Pelvic muscle exercises can help strengthen these muscles. The other choices would cause the incontinence to worsen.

DIF: Cognitive Level: Application REF: p. 364 OBJ: 1
TOP: Anorectal Incontinence KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

21. Which result of postvoid catheterization would indicate positive bladder emptying?
a. Less than 125 mL
b. Less than 100 mL
c. Less than 75 mL
d. Less than 50 mL
ANS: D
If the catheterization immediately after voiding is less than 50 mL, the voiding can be viewed as adequate or normal.

DIF: Cognitive Level: Knowledge REF: p. 349 OBJ: 4
TOP: Postvoid Catheterization Evaluation
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

22. A nurse is cleaning a patient with fecal incontinence when the patient says, This is so embarrassing, and it makes me really angry. What is the nurses best response?
a. Dont worry about it; its my job to clean you up.
b. If you would have called me sooner, this wouldnt have happened.
c. Do you feel angry and embarrassed?
d. Would you rather let your family clean you up?
ANS: C
The nurse should use therapeutic communications of reflection to validate the patients feelings.

DIF: Cognitive Level: Application REF: p. 365 OBJ: 1
TOP: Fecal Incontinence KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

23. What foods should a nurse explain to a patient can cause diarrhea?
a. Cheese
b. Cabbage
c. Rice
d. Yogurt
ANS: B
Foods such as cabbage, raw vegetables, and spicy foods can cause diarrhea. Cheese, rice, and yogurt thicken stool.

DIF: Cognitive Level: Knowledge REF: p. 363 OBJ: 5
TOP: Dietary Changes to Reduce Diarrhea
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

24. A patient with fecal incontinence should be taught the importance of maintaining good skin integrity. What should be the focus of a nurses teaching?
a. Cleanse the perianal area thoroughly after each stool.
b. Use a fecal pouch.
c. Change incontinence undergarments once a day.
d. Take an over-the-counter laxative daily.
ANS: A
Skin integrity can be best maintained by keeping the perianal area clean and dry. The other choices may cause an impairment of skin integrity.

DIF: Cognitive Level: Application REF: p. 365 OBJ: 5
TOP: Skin Integrity KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

25. What is the cause of symptomatic incontinence?
a. Colorectal disease
b. Gastrocolic reflex
c. Constipation
d. Nerve damage
ANS: A
Symptomatic incontinence is the result of colorectal disease. Medical care should be sought to identify and treat the cause.

DIF: Cognitive Level: Knowledge REF: p. 364 OBJ: 3
TOP: Symptomatic Incontinence KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

26. A patient asks a home health nurse if the periurethral bulking procedure will be a permanent remedy to urinary incontinence. On what knowledge regarding the effects of this procedure should the nurse base a response?
a. Are permanent
b. Are only helpful to men
c. Usually last for approximately 6 months
d. Remain for 2 or 3 years
ANS: D
The periurethral bulking procedure that injects a bulking product around the urinary meatus usually has to be repeated every 2 to 3 years.

DIF: Cognitive Level: Comprehension REF: p. 350 OBJ: 1
TOP: Periurethral Bulking KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

27. What does the uroflowmetry diagnostic tool measure?
a. Voiding duration
b. Specific gravity of urine
c. Effectiveness of the detrusor muscle
d. General bladder tone
ANS: A
The uroflowmetry is a diagnostic tool designed to measure voiding duration, rate, and amount.

DIF: Cognitive Level: Knowledge REF: p. 348 OBJ: 1
TOP: Uroflowmetry KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

MULTIPLE RESPONSE

28. Which statements by a patient would indicate an accurate understanding of cytometry? (Select all that apply.)
a. Drink no fluids for 6 hours after the test.
b. Report a change in my abdominal girth.
c. Notify the doctor if I have difficulty voiding.
d. Sleep on my stomach.
e. Notify my doctor if I experience burning on urination.
ANS: C, E
Voiding difficulty and burning on urination are complications that should be reported to the physician. Neither fluid intake nor sleeping positions are restricted. Abdominal girth is not significant to the postcystometry recovery.

DIF: Cognitive Level: Comprehension REF: p. 348 OBJ: 1
TOP: Cytometry KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

29. What should a nurse include when providing instructions to a patient as to what to do when feeling the urge to void? (Select all that apply.)
a. Breathe deeply and try to relax.
b. Perform several Kegel maneuvers without resting in between.
c. Walk to the bathroom at a normal pace while performing Kegel maneuvers.
d. Distract herself with a book or a television program.
e. Stop what she is doing and sit down or stand quietly.
ANS: A, B, C, E
Breathing deeply, trying to relax, and performing Kegel maneuvers are all helpful in urge suppression. Distraction is seldom effective.

DIF: Cognitive Level: Comprehension REF: p. 350 OBJ: 1
TOP: Urge Suppression KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

30. What should the nurse include in the plan of care to protect the skin integrity of an incontinent patient? (Select all that apply.)
a. Immediately remove wet garments and linens.
b. Wash skin with an antiseptic and towel dry.
c. Inspect for areas of redness and breakdown every morning.
d. Apply cornstarch to the perineum to absorb moisture.
e. Apply protective creams per agency policy.
ANS: A, E
Any wet clothing or linens should be removed, and protective creams should be applied according to agency policy. Applying an antiseptic or cornstarch is not recommended because antiseptics are drying and cornstarch gives rise to yeast infections. The skin should be inspected every time the brief is changed.

DIF: Cognitive Level: Application REF: p. 365 OBJ: 4
TOP: Skin Integrity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

31. Which is true regarding the habit training technique prompted voiding? (Select all that apply.)
a. Is useful with cognitively impaired persons
b. Helps the patient to recognize incontinence
c. Is based on giving praise for staying dry
d. Strengthens the pelvic floor
e. Uses the Valsalva maneuver to force urine from bladder
ANS: A, B, C
Prompted voiding technique is used with cognitively impaired persons. This technique helps the patient recognize incontinence and the praise for staying dry.

DIF: Cognitive Level: Comprehension REF: p. 349 OBJ: 1
TOP: Prompted Voiding KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

COMPLETION

32. A patient complains, My allergies make me sneeze and urinate in my pants. I take my allergy drug and I urinate in my pants even more. The nurse assesses that the drug the patient is referring to is a(n) _____.

ANS:
antihistamine
Many antihistamine preparations increase the incidence of incontinence.

DIF: Cognitive Level: Application REF: p. 357 OBJ: 4
TOP: Drugs That Increase Incontinence KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

33. A nurse explains that the normal bladder will empty when it reaches the capacity of _____ to _____ mL.

ANS:
200; 250
The urge to void will occur when the bladder is holding 200 to 250 mL of urine.

DIF: Cognitive Level: Comprehension REF: p. 348 OBJ: 2
TOP: Bladder Capacity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

34. The method by which a nurse manually expresses urine from the bladder by pressing gently on the lower abdomen is the _____ method.

ANS:
Cred
The Cred method calls for the manual expressing of urine from the bladder be gently pressing down on the lower abdomen and pressing the bladder.

DIF: Cognitive Level: Knowledge REF: p. 355 OBJ: 1
TOP: Cred Method KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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