A nurse is assessing a client who has dehydration.
Which of the following findings should the nurse expect?
Cloudy urine.
Urine osmolality of 200 mOsm/kg.
Urine specific gravity of 1.015.
Dark-colored urine.
The Correct Answer is D
Choice D rationale
Dark-colored urine is a common indicator of dehydration. When the body is dehydrated, urine becomes more concentrated, leading to darker color due to higher levels of waste products.
Choice A rationale
Cloudy urine is not typically associated with dehydration. It may indicate the presence of an infection, inflammation, or other medical conditions.
Choice B rationale
Urine osmolality of 200 mOsm/kg suggests diluted urine, which is contrary to the expectation in dehydration. Dehydration would typically result in higher urine osmolality as the kidneys conserve water.
Choice C rationale
Urine specific gravity of 1.015 falls within the normal range (1.005 to 1.030). In dehydration, specific gravity would be expected to be higher as the urine becomes more concentrated to conserve water.
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Correct Answer is A
Explanation
Choice A rationale
Reflex incontinence is caused by neurological impairment or damage, such as spinal cord injury, which results in a loss of voluntary control over urination. The bladder muscle contracts involuntarily, causing urine leakage.
Choice B rationale
Overflow incontinence occurs when the bladder cannot empty properly, leading to frequent or constant dribbling of urine. It is not typically associated with nerve damage from spinal cord injury.
Choice C rationale
Stress incontinence is caused by physical movement or activity—such as coughing, sneezing, or heavy lifting—that puts pressure on the bladder, leading to urine leakage. It is not related to nerve damage or neurological conditions.
Choice D rationale
Urge incontinence is characterized by a sudden, intense urge to urinate, followed by involuntary urine leakage. It is usually caused by an overactive bladder or other conditions affecting bladder function, but not directly by nerve damage from spinal cord injury.
Correct Answer is C
Explanation
Choice A rationale
The end of the stoma is typically not painful after the procedure. Pain at the stoma site could indicate complications such as infection or ischemia.
Choice B rationale
A healthy stoma should be pink or red in color. A purple color could indicate compromised blood flow or other complications that require medical attention.
Choice C rationale
The stoma is typically placed in the right lower abdomen to allow for easier management and care, as it is usually associated with the terminal ileum.
Choice D rationale
After an ileostomy, the stool is usually liquid to semi-formed, not solid, because the colon, which absorbs water to solidify stool, is bypassed.