A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury.
The nurse should identify that the client is experiencing which of the following types of urinary incontinence?
Reflex incontinence.
Overflow incontinence.
Stress incontinence.
Urge incontinence.
The Correct Answer is A
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.
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Correct Answer is D
Explanation
Choice A rationale
Blood in the urine (hematuria) is not a typical finding in urinary retention. It may indicate other conditions such as infection, stones, or malignancy.
Choice B rationale
Cloudy urine is often a sign of infection, not typically associated with urinary retention. It can be caused by the presence of bacteria, white blood cells, or crystals.
Choice C rationale
Dark-colored urine can result from dehydration or certain foods and medications. It is not a specific finding of urinary retention.
Choice D rationale
Leakage of urine, also known as overflow incontinence, can occur in urinary retention. This happens when the bladder becomes overly full, and small amounts of urine leak out due to the pressure.
Correct Answer is D
Explanation
Choice A rationale
It is best practice to use a new cotton swab for each swipe to avoid contamination. Each area should be cleaned with a separate cotton swab.
Choice B rationale
Oil-based lubricants should not be used with catheters as they can interfere with the material of the catheter. Water-based lubricants are preferred.
Choice C rationale
Testing the balloon on the indwelling urinary catheter before insertion can lead to an increased risk of contamination and potential damage to the catheter.
Choice D rationale
Sterile gloves are essential to prevent infection during the insertion of an indwelling urinary catheter. Maintaining a sterile field is crucial.