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 B
Explanation
Choice A rationale
Placing the client into a right lateral position is not the standard position for administering an enema. The left lateral (Sims') position is commonly used as it facilitates the flow of the
solution into the colon.
Choice B rationale
Warming the enema solution to room temperature helps ensure the client's comfort and can prevent cramping and discomfort. Cold solutions can cause discomfort and cramping,
making the procedure less tolerable for the client.
Choice C rationale
Sterile technique is not required for administering an enema. Clean technique is generally sufficient unless otherwise indicated by the client’s condition or specific medical orders.
Choice D rationale
Lubricating the tubing is essential to ensure smooth insertion and prevent trauma to the rectal mucosa, but an oil-based lubricant is not typically used as it can interfere with the
absorption of the enema solution. Water-soluble lubricants are preferred.
Correct Answer is A
Explanation
Choice A rationale
Neobladder urinary diversion involves creating an internal reservoir or pouch from a segment of the intestine to store urine. This new bladder is then connected to the urethra,
enabling the client to void through the urethra. This method closely mimics natural urination, allowing the client to have some control over urination.
Choice B rationale
This is incorrect because a neobladder is designed to allow the client to control urination. While there might be a learning curve for the client to adapt to the new bladder, the ultimate
goal is to achieve continence.
Choice C rationale
This describes an ileal conduit, another type of urinary diversion, where a stoma is created on the abdomen for urine to pass into an external bag. The neobladder does not involve a
stoma for urination.
Choice D rationale
This is incorrect as it pertains to an ileal conduit or urostomy. Clients with a neobladder do not require an external collection bag since urine is stored internally in the constructed
bladder and can be passed through the urethra. .