Chapter 10: Elimination My Nursing Test Banks

Chapter 10: Elimination

Test Bank

MULTIPLE CHOICE

1. Which of the following is a true statement about elimination in older adults?

a.

Defecation less than once each day is not necessarily constipation.

b.

Mineral oil is recommended as a laxative for the older adult.

c.

Excessive sleep can be a symptom of constipation.

d.

Leaking liquid feces should be treated as diarrhea.

ANS: A

Constipation is present when fewer than three bowel movements occur per week or when the frequency decreases. Mineral oil and saline laxatives can be harmful. Fiber, fruit, and fluids are the first recommendations; stimulant laxatives such as senna and cascara can be used on a short-term basis. Altered cognitive status, increased agitation, and unexplained falls can be symptoms of constipation; these behaviors may be the only clinical symptom of constipation in cognitively impaired older persons. Excessive sleep has not been identified as a symptom. Liquid feces may be leaking around a fecal impaction, and antidiarrheal treatment can aggravate the impaction.

PTS:1DIF:RememberREF:13-21

TOP: Nursing Process: Assessment MSC: Physiological Integrity

2. Which action should be included in all bladder-retraining programs?

a.

Toileting at bedtime

c.

Toileting every hour

b.

Using adult incontinence pads

d.

Providing 1000 ml of fluids daily

ANS: A

Toileting at bedtime should be incorporated for all patients. This intervention decreases the amount of urine in the bladder during the night. Incontinence pads are not encouraged during the retraining process. Toileting is not automatically scheduled every hour but is based on the individuals needs. The volume of scheduled fluid intake is also based on the individuals needs.

PTS: 1 DIF: Apply REF: 13-21 TOP: Nursing Process: Planning

MSC: Physiological Integrity

3. The nurse understands that stress incontinence occurs:

a.

With a urinary tract infection (UTI)

b.

Because of emotional strain

c.

As a result of increased intraabdominal pressure

d.

With a specific amount of urine in the bladder

ANS: C

If intraabdominal pressure increases, then the patient can have dribbling. A UTI causes frequency as a result of irritation in the bladder. Emotional strain can cause frequency. Specific volume of urine in the bladder triggers reflex incontinence.

PTS:1DIF:UnderstandREF:5-7

TOP: Nursing Process: Assessment MSC: Health Promotion and Maintenance

4. What is the most important aspect of care for the nurse to maintain when assisting an older patient with urinary incontinence?

a.

Availability of protective rubber garments

b.

Using indwelling urinary catheters

c.

Using smooth muscle relaxants

d.

Maintaining an attitude that is respectful and positive about resolving the problem

ANS: D

The nurse recognizes that incontinence is a sign of an underlying problem and not an inevitable result of aging. In addition, the nurse offers dignity, hope, and understanding by maintaining a positive and respectful manner and by communicating that effective treatments are available. Rubber garments, in particular, are hot and can cause skin irritation. Internal catheters should be used only for a short time and under limited circumstances. Using a smooth muscle relaxant is indicated only for urge incontinence and for an overactive bladder.

PTS:1DIF:UnderstandREF:32 Box 10-3

TOP: Nursing Process: Implementation MSC: Health Promotion and Maintenance

5. Which option is part of a program that addresses bowel incontinence in an older adult patient?

a.

Ensuring that a toilet or commode is readily accessible to the patient

b.

Encouraging the intake of 1 liter of water each day

c.

Expecting a rapid and full recovery

d.

Toileting the patient 10 to 15 minutes after meals

ANS: A

Difficult access to facilities within the time available is a factor in bowel incontinence and bladder incontinence. The intake of 1 L of fluid is less than the recommended amount to protect against dehydration and constipation. Realistic expectations and goals should be discussed with the patient. Toileting should occur 20 to 40 minutes after regularly scheduled meals when the gastrocolic reflex is active.

PTS: 1 DIF: Remember REF: 38 Box 10-7 TOP: Nursing Process: Planning

MSC:Health Promotion and Maintenance

6. An older adult who is on bed rest after surgery is prescribed morphine for pain. Which of the following is the nurses priority for preventive care?

a.

Constipation

c.

Poor solid food intake

b.

Diarrhea

d.

Poor liquid intake

ANS: A

This older adult is at high risk for developing constipation as a result of being on bed rest and being prescribed an opiate for pain. A decrease in activity, combined with the use of an opiate, often leads to constipation, not diarrhea. Appetite can be poor for the first few days after surgery, but it often returns without incidence. Decreased fluid intake is often supplemented with intravenous fluids for the first few days after surgery.

PTS:1DIF:ApplyREF:35-36 Box 10-5

TOP: Nursing Process: Planning MSC: Health Promotion and Maintenance

7. The nurse is caring for a patient who has recently had an indwelling catheter placed. The nurse should assess the patient for:

a.

An increase in oral fluid intake

c.

Upper back pain

b.

A change in mental status

d.

A decrease in activity

ANS: B

The nurse assesses the older adults mental status. Changes in mental status, character of urine, decreased appetite, abdominal pain, chills, low back pain, urethral discharge in men, new onset of incontinence, or even respiratory distress may signal a possible UTI in older people. An indwelling catheter does not often cause a decrease in activity.

PTS:1DIF:ApplyREF:11

TOP: Nursing Process: Assessment MSC: Physiological Integrity

8. The nurse assesses a male resident in a nursing home for urinary incontinence and determines that he is unaware of the problem. Which recommendation should the nurse implement?

a.

Limit oral fluid intake.

c.

Apply absorbent undergarment.

b.

Provide regular toileting.

d.

Encourage frequent rest periods.

ANS: B

The nurse provides regular toileting to promote voiding and to prevent incontinence for a resident with a potential cognitive impairment. The nurse avoids limiting oral fluid intake; older adults, especially those living in residential facilities, are at higher risk for dehydration than younger people. Using absorbent undergarments may be unnecessary if the incontinence can be controlled with regular toileting. Nursing research supports the claim that ambulatory residents are less likely to be incontinent. This resident may have dementia, but maintaining mobility will have a greater impact in preventing incontinence.

PTS:1DIF:ApplyREF:32-35 Boxes 3 & 4

TOP: Nursing Process: Planning MSC: Health Promotion and Maintenance

9. A large residual urine volume characterizes what type of incontinence?

a.

Urge

c.

Overflow

b.

Stress

d.

Functional

ANS: C

Dribbling, hesitancy, and a large residual urine volume characterize overflow incontinence. Both urge incontinence and stress incontinence are associated with a small residual urine volume. Functional incontinence is not associated with residual urine volume.

PTS:1DIF:RememberREF:5-7

TOP: Nursing Process: Assessment MSC: Physiological Integrity

10. An older adult is in the hospital because of heart failure and has become incontinent of urine. Which evidence-based resource should the nurse use to guide continence care for this patient?

a.

Nursing Standard Practice Protocol

b.

The Borun Center training modules

c.

Toolkit from the American Geriatrics Society

d.

The Centers for Medicare and Medicaid Services

ANS: A

The Nursing Standard Practice Protocol is a resource for urinary incontinence in older adults admitted to acute care. The Borun Center provides training modules suitable for nurses managing incontinence in residents in long-term care facilities. The American Geriatrics Society helps with managing urinary incontinence in primary care settings. The Centers for Medicare and Medicaid Services supply guidelines for managing urinary incontinence in long-term care facilities.

PTS: 1 DIF: Understand REF: 5-10 TOP: Nursing Process: Planning

MSC:Health Promotion and Maintenance

11. The nurse wants to begin helping a resident who is overweight and has urinary incontinence with healthy bladder behavior skills. Which intervention should the nurse implement?

a.

Begin a low-calorie diet for weight management.

b.

Schedule voiding at 2- to 4-hour intervals.

c.

Instruct the resident to practice abdominal exercises.

d.

Reduce the time between an urge to void and voiding.

ANS: B

Healthy bladder behavior skills include scheduling voiding at 2- to 4-hour intervals for residents either independently or with prompting. Beginning a low-calorie diet can be a reasonable approach to urinary incontinence, but the nurse first applies low-cost behavioral techniques. Pelvic floor exercises will help control urinary incontinence. Bladder training involves increasing the time between the urge to void and voiding.

PTS:1DIF:ApplyREF:32-35 Boxes

TOP: Nursing Process: Implementation MSC: Health Promotion and Maintenance

12. An older woman tells the nurse practitioner that she fears her family will place her in a nursing home because she developed stress incontinence. Which recommendation should the nurse implement?

a.

Tell her to eliminate the use of caffeinated beverages.

b.

Coordinate a family conference with the older adult.

c.

Recommend exercises to strengthen the pelvic floor.

d.

Schedule voiding for every 2 hours around the clock.

ANS: C

The nurse practitioner recommends pelvic floor exercises to strengthen the pelvic floor and the muscles that surround the urethra, vagina, and rectum to decrease the incidence of stress incontinence. Stress incontinence is usually due to weakened pelvic floor muscles; therefore eliminating caffeinated beverages can be an ineffective treatment. Arranging a family conference is premature and potentially embarrassing for the older adult. Many therapies are available to decrease this older adults incontinence. Scheduled voiding is recommended at 2- to 4-hour intervals during the day and at 4-hour intervals at night.

PTS:1DIF:ApplyREF:32-35 Boxes

TOP: Nursing Process: Implementation MSC: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. Which signs and symptoms are characteristic of a urinary tract infection (UTI) in an older adult? (Select all that apply.)

a.

Fever

b.

Uremia

c.

Dysuria

d.

Anorexia

e.

Flank pain

f.

Turbid urine

ANS: D, F

Anorexia is a more reliable indicator of a UTI in an older adult. In addition, individuals, including older adults, are likely to void cloudy urine when a UTI is present. Fever, uremia, dysuria, and flank pain are all unreliable indicators of a UTI in the older adult.

PTS:1DIF:RememberREF:11-13

TOP: Nursing Process: Assessment MSC: Health Promotion and Maintenance

2. Long-term use of external catheters can lead to which complication(s)? (Select all that apply.)

a.

Fungal skin infections

b.

Penile skin maceration

c.

Atrophy

d.

Edema

e.

Phimosis

ANS: A, B, D, E

Long-term use of external catheters can lead to fungal skin infections, penile skin maceration, edema, fissures, contact burns from urea, phimosis, UTIs, and septicemia. The catheter should be removed and replaced daily and the penis cleaned, dried, and aired to prevent irritation, maceration, and the development of pressure ulcers and skin breakdown. If the catheter is not sized appropriately and applied and monitored correctly, then strangulation of the penile shaft can occur. Atrophy has not been identified as a complication.

PTS:1DIF:RememberREF:11

TOP: Nursing Process: Assessment MSC: Health Promotion and Maintenance

3. Continuous indwelling catheter use is indicated for which condition(s)? (Select all that apply.)

a.

Urethral obstruction

c.

Stress incontinence

b.

Urinary retention

d.

Severely impaired skin integrity

ANS: A, B, D

Continuous indwelling catheter use is indicated for those with urethral obstruction or urinary retention because these patients are unable to empty their bladder without this device. Stress incontinence is not a condition that warrants a continuous indwelling catheter. Continuous indwelling catheter use is indicated for patients with severely impaired skin integrity to decrease the risk of further deterioration of skin integrity.

PTS:1DIF:RememberREF:10

TOP: Nursing Process: Assessment MSC: Health Promotion and Maintenance

OTHER

1. The nurse evaluates the urinalysis (UA) of a female patient with an indwelling urinary catheter. The UA report shows gross contamination of the urine. Rank the nursing interventions in order, beginning with the first intervention the nurse should implement.

A. Provide perineal hygiene.

B. Provide urinary catheter care.

C. Check the duration of catheterization.

D. Obtain a urine specimen from a sterile port.

ANS:

C, B, A, D

Gross contamination of a urine specimen is a costly error because contaminated urine is unsuitable for evaluation. The nurse responds to the report of contamination by determining how long the catheter has been in place; increased duration increases the risk of a UTI from fecal contamination and can affect subsequent nursing interventions. The second intervention is providing catheter care. Regardless of the cause of the specimen contamination, catheter care is a suitable nursing intervention because it decreases the colony count on the catheter. Third, the nurse progresses to perineal care. This intervention follows catheter care because of the principle of asepsis regarding working from the least contaminated to the most contaminated area. Finally, the nurse obtains another urine specimen from a sterile port. Although the catheter has been washed, the nurse rubs the port with alcohol and withdraws urine with a sterile needle and syringe to prevent the introduction of contaminants into the specimen.

PTS:1DIF:AnalyzeREF:10-13| 29 Box 10-1

TOP: Nursing Process: Planning MSC: Health Promotion and Maintenance

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