Nursing: A Concept-Based Approach to Learning, 2e (Pearson)

Module 5 Elimination

The Concept of Elimination

1) The nurse is caring for a female client on a medical-surgical unit. The client tells the nurse, "I
don't get any sleep at night because I have to get up and use the bathroom every couple of
hours!" Which of the following explanations by the nurse would be most accurate to explain the
client's nocturia?
A) "As you get older, there is a decrease in number of nephrons."
B) "As you get older, there is a decrease in the blood supply to your bladder."
C) "As you get older, you may have a decrease in bladder capacity."
D) "As you get older, there is a decrease in cardiac output, which can cause your symptoms."
Answer: C
Explanation: A) Approximately 70% of older women and 50% of older men have to get up two
or more times during the night to empty their bladders due to decreased bladder capacity. A
decrease in blood supply causes an increase in urine concentration. A decrease in the number of
nephrons decreases the filtration rate. A decrease in cardiac output decreases peripheral
circulation, which would decrease urinary output day or night.
B) Approximately 70% of older women and 50% of older men have to get up two or more times
during the night to empty their bladders due to decreased bladder capacity. A decrease in blood
supply causes an increase in urine concentration. A decrease in the number of nephrons
decreases the filtration rate. A decrease in cardiac output decreases peripheral circulation, which
would decrease urinary output day or night.
C) Approximately 70% of older women and 50% of older men have to get up two or more times
during the night to empty their bladders due to decreased bladder capacity. A decrease in blood
supply causes an increase in urine concentration. A decrease in the number of nephrons
decreases the filtration rate. A decrease in cardiac output decreases peripheral circulation, which
would decrease urinary output day or night.
D) Approximately 70% of older women and 50% of older men have to get up two or more times
during the night to empty their bladders due to decreased bladder capacity. A decrease in blood
supply causes an increase in urine concentration. A decrease in the number of nephrons
decreases the filtration rate. A decrease in cardiac output decreases peripheral circulation, which
would decrease urinary output day or night.
Page Ref: 263
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 1. Summarize the physiology of the renal and gastrointestinal systems
related to elimination.

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2) A 53-year-old woman has high blood pressure that is not responding to medications. Where
should you auscultate if you suspect renal stenosis?
A) renal arteries
B) kidneys
C) ureters
D) internal urethral sphincter
E) bladder
Answer: A
Explanation: A) The nurse should auscultate the renal arteries by placing the bell of the
stethoscope lightly in the areas of the renal arteries, located in the left and right upper abdominal
quadrants. Systolic bruits ("whooshing" sounds) may indicate renal artery stenosis.
B) The nurse should auscultate the renal arteries by placing the bell of the stethoscope lightly in
the areas of the renal arteries, located in the left and right upper abdominal quadrants. Systolic
bruits ("whooshing" sounds) may indicate renal artery stenosis.
C) The nurse should auscultate the renal arteries by placing the bell of the stethoscope lightly in
the areas of the renal arteries, located in the left and right upper abdominal quadrants. Systolic
bruits ("whooshing" sounds) may indicate renal artery stenosis.
D) The nurse should auscultate the renal arteries by placing the bell of the stethoscope lightly in
the areas of the renal arteries, located in the left and right upper abdominal quadrants. Systolic
bruits ("whooshing" sounds) may indicate renal artery stenosis.
E) The nurse should auscultate the renal arteries by placing the bell of the stethoscope lightly in
the areas of the renal arteries, located in the left and right upper abdominal quadrants. Systolic
bruits ("whooshing" sounds) may indicate renal artery stenosis.
Page Ref: 269
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Summarize the physiology of the renal and gastrointestinal systems
related to elimination.

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3) The nurse is caring for a group of clients on a medical-surgical nursing unit. The nurse knows
that which client is most at risk for difficulty in urinary elimination?
A) The client with hypertension who takes a diuretic every day for her blood pressure
B) An 80-year-old male reporting frequent urination at night
C) A 25-year-old female client with low self-esteem
D) A client who had bladder cancer and now has a newly created ileal conduit
Answer: B
Explanation: A) The client who is 80 years old with frequent urination at night is having
problems with his prostate. Older male adults experience urinary retention due to prostate
enlargement causing an alteration in urinary elimination. The 25-year-old experiencing low self-
esteem has a psychological problem and will need therapy to find the root of the problem. The
client who had bladder cancer and now has an ileal conduit doesn't have kidney damage, only the
bladder removed. Continued urine production through the ileal conduit will need to be observed
and assessed frequently by the staff. The client with high blood pressure takes her medication to
remove excess fluid from her body, and as long as urine elimination increases, there should be no
problems.
B) The client who is 80 years old with frequent urination at night is having problems with his
prostate. Older male adults experience urinary retention due to prostate enlargement causing an
alteration in urinary elimination. The 25-year-old experiencing low self-esteem has a
psychological problem and will need therapy to find the root of the problem. The client who had
bladder cancer and now has an ileal conduit doesn't have kidney damage, only the bladder
removed. Continued urine production through the ileal conduit will need to be observed and
assessed frequently by the staff. The client with high blood pressure takes her medication to
remove excess fluid from her body, and as long as urine elimination increases, there should be no
problems.
C) The client who is 80 years old with frequent urination at night is having problems with his
prostate. Older male adults experience urinary retention due to prostate enlargement causing an
alteration in urinary elimination. The 25-year-old experiencing low self-esteem has a
psychological problem and will need therapy to find the root of the problem. The client who had
bladder cancer and now has an ileal conduit doesn't have kidney damage, only the bladder
removed. Continued urine production through the ileal conduit will need to be observed and
assessed frequently by the staff. The client with high blood pressure takes her medication to
remove excess fluid from her body, and as long as urine elimination increases, there should be no
problems.

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D) The client who is 80 years old with frequent urination at night is having problems with his
prostate. Older male adults experience urinary retention due to prostate enlargement causing an
alteration in urinary elimination. The 25-year-old experiencing low self-esteem has a
psychological problem and will need therapy to find the root of the problem. The client who had
bladder cancer and now has an ileal conduit doesn't have kidney damage, only the bladder
removed. Continued urine production through the ileal conduit will need to be observed and
assessed frequently by the staff. The client with high blood pressure takes her medication to
remove excess fluid from her body, and as long as urine elimination increases, there should be no
problems.
Page Ref: 258
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 2. Examine the relationship between elimination and other
concepts/systems.

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4) The nurse is caring for a client with a history of urinary tract infections (UTI). Which
intervention should the nurse implement for the client in helping to prevent future UTIs?
A) Instruct the client to completely empty the bladder.
B) Tell the client to increase sugar in the diet.
C) Encourage the client to take bubble baths.
D) Remind the client to wipe from back to front.
Answer: A
Explanation: A) Completely emptying the bladder prevents stasis of urine, which would
contribute to a urinary tract infection. Irritating soaps and bubble baths can contribute to
infections and should be avoided. The client should wipe from front to back because wiping from
back to front would contaminate the urinary meatus. The client should decrease the use of sugar
in the diet because sugar promotes bacterial growth.
B) Completely emptying the bladder prevents stasis of urine, which would contribute to a urinary
tract infection. Irritating soaps and bubble baths can contribute to infections and should be
avoided. The client should wipe from front to back because wiping from back to front would
contaminate the urinary meatus. The client should decrease the use of sugar in the diet because
sugar promotes bacterial growth.
C) Completely emptying the bladder prevents stasis of urine, which would contribute to a urinary
tract infection. Irritating soaps and bubble baths can contribute to infections and should be
avoided. The client should wipe from front to back because wiping from back to front would
contaminate the urinary meatus. The client should decrease the use of sugar in the diet because
sugar promotes bacterial growth.
D) Completely emptying the bladder prevents stasis of urine, which would contribute to a
urinary tract infection. Irritating soaps and bubble baths can contribute to infections and should
be avoided. The client should wipe from front to back because wiping from back to front would
contaminate the urinary meatus. The client should decrease the use of sugar in the diet because
sugar promotes bacterial growth.
Page Ref: 265
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 3. Identify commonly occurring alterations in elimination and their related
therapies.

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5) The nurse is admitting a client to the medical unit for a urinary disorder. Which physical
assessment technique will the nurse use in assessing this client's urinary system?
Select all that apply.
A) Auscultation
B) Palpation
C) Inspection
D) Percussion
E) Ultrasound
Answer: A, B, C
Explanation: A) The hands and sense of touch are used with palpation to gather data along with
observation or inspection, which visually allows the nurse to observe all responses and nonverbal
behavior. It is also the most frequently used technique and the most convenient. Auscultation is
the technique of listening. The three systems that should be assessed using this technique are
cardiovascular, respiratory, and gastrointestinal. Percussion technique is the least frequently used
by nurses, and it would cause discomfort if this client were already uncomfortable with a kidney
condition. The nurse should not make matters worse. An ultrasound is typically an assessment
technique performed by the bedside nurse.
B) The hands and sense of touch are used with palpation to gather data along with observation or
inspection, which visually allows the nurse to observe all responses and nonverbal behavior. It is
also the most frequently used technique and the most convenient. Auscultation is the technique
of listening. The three systems that should be assessed using this technique are cardiovascular,
respiratory, and gastrointestinal. Percussion technique is the least frequently used by nurses, and
it would cause discomfort if this client were already uncomfortable with a kidney condition. The
nurse should not make matters worse. An ultrasound is typically an assessment technique
performed by the bedside nurse.
C) The hands and sense of touch are used with palpation to gather data along with observation or
inspection, which visually allows the nurse to observe all responses and nonverbal behavior. It is
also the most frequently used technique and the most convenient. Auscultation is the technique
of listening. The three systems that should be assessed using this technique are cardiovascular,
respiratory, and gastrointestinal. Percussion technique is the least frequently used by nurses, and
it would cause discomfort if this client were already uncomfortable with a kidney condition. The
nurse should not make matters worse. An ultrasound is typically an assessment technique
performed by the bedside nurse.
D) The hands and sense of touch are used with palpation to gather data along with observation or
inspection, which visually allows the nurse to observe all responses and nonverbal behavior. It is
also the most frequently used technique and the most convenient. Auscultation is the technique
of listening. The three systems that should be assessed using this technique are cardiovascular,
respiratory, and gastrointestinal. Percussion technique is the least frequently used by nurses, and
it would cause discomfort if this client were already uncomfortable with a kidney condition. The
nurse should not make matters worse. An ultrasound is typically an assessment technique
performed by the bedside nurse.

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E) The hands and sense of touch are used with palpation to gather data along with observation or
inspection, which visually allows the nurse to observe all responses and nonverbal behavior. It is
also the most frequently used technique and the most convenient. Auscultation is the technique
of listening. The three systems that should be assessed using this technique are cardiovascular,
respiratory, and gastrointestinal. Percussion technique is the least frequently used by nurses, and
it would cause discomfort if this client were already uncomfortable with a kidney condition. The
nurse should not make matters worse. An ultrasound is typically an assessment technique
performed by the bedside nurse.
Page Ref: 267
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 4. Differentiate common assessment procedures used to examine urinary
and gastrointestinal health across the life span.

6) The client with a urinary disorder is admitted to the urology unit of the hospital. Which of the
following urinalysis results would indicate a urinary tract infection?
A) pH 5.2
B) Negative glucose
C) WBC 10-15
D) Specific gravity 1.012
Answer: C
Explanation: A) A urinalysis typically consists of the pH, glucose, specific gravity, protein, and
WBC count. The pH, glucose and specific gravity are all within normal limits. A normal WBC is
0-4. The WBC count for this client is high and indicates infection.
B) A urinalysis typically consists of the pH, glucose, specific gravity, protein, and WBC count.
The pH, glucose and specific gravity are all within normal limits. A normal WBC is 0-4. The
WBC count for this client is high and indicates infection.
C) A urinalysis typically consists of the pH, glucose, specific gravity, protein, and WBC count.
The pH, glucose and specific gravity are all within normal limits. A normal WBC is 0-4. The
WBC count for this client is high and indicates infection.
D) A urinalysis typically consists of the pH, glucose, specific gravity, protein, and WBC count.
The pH, glucose and specific gravity are all within normal limits. A normal WBC is 0-4. The
WBC count for this client is high and indicates infection.
Page Ref: 271
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 5. Describe diagnostic and laboratory tests to determine the individual's
elimination status.

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7) The nurse is preparing to discharge a client with urinary diversion. The nurse anticipates that
the client will require some teaching prior to going home. Which point will the nurse incorporate
into the plan?
A) Instructing the client to notify the physician if the stoma is deep pink and shiny
B) Instructing the client that strands of blood may appear in the urine
C) The need to change the appliance every day
D) The importance of increasing fluid intake
Answer: D
Explanation: A) Increasing the fluid intake helps to flush out sediment and mucus and prevents
clogging of the stoma. The appliance should be changed every 5-7 days. Everyday changing is
unnecessary. A deep pink, shiny stoma is normal and does not require the notification of the
physician. Strands of mucus, not blood, may appear in urine because of the mucus-producing
cells of the ileum.
B) Increasing the fluid intake helps to flush out sediment and mucus and prevents clogging of the
stoma. The appliance should be changed every 5-7 days. Everyday changing is unnecessary. A
deep pink, shiny stoma is normal and does not require the notification of the physician. Strands
of mucus, not blood, may appear in urine because of the mucus-producing cells of the ileum.
C) Increasing the fluid intake helps to flush out sediment and mucus and prevents clogging of the
stoma. The appliance should be changed every 5-7 days. Everyday changing is unnecessary. A
deep pink, shiny stoma is normal and does not require the notification of the physician. Strands
of mucus, not blood, may appear in urine because of the mucus-producing cells of the ileum.
D) Increasing the fluid intake helps to flush out sediment and mucus and prevents clogging of the
stoma. The appliance should be changed every 5-7 days. Everyday changing is unnecessary. A
deep pink, shiny stoma is normal and does not require the notification of the physician. Strands
of mucus, not blood, may appear in urine because of the mucus-producing cells of the ileum.
Page Ref: 303
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Explain management of urinary and bowel health and prevention of
urinary and bowel illness.

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8) The nurse is caring for an elderly male client who has returned to the unit following a
resection of the prostate (TURP). The client has a three-way indwelling catheter. The client tells
the nurse that he has to urinate. Which of the following nursing interventions is most
appropriate?
A) Deflate and then reinflate the catheter balloon.
B) Irrigate the catheter.
C) Retape the catheter to the abdomen.
D) Reposition the catheter.
Answer: C
Explanation: A) Blood clots give the client the sensation to urinate when they obstruct the urine
outflow; therefore, irrigation will have to remedy the problem. Deflating and reinflating the
balloon is not an option. The surgeon knows how much pressure is needed to control bleeding
after surgery. The catheter is usually taped to the client's leg after a TURP and is not to be
manipulated. This also controls bleeding after surgery. Repositioning the catheter would not be
an option right after surgery.
B) Blood clots give the client the sensation to urinate when they obstruct the urine outflow;
therefore, irrigation will have to remedy the problem. Deflating and reinflating the balloon is not
an option. The surgeon knows how much pressure is needed to control bleeding after surgery.
The catheter is usually taped to the client's leg after a TURP and is not to be manipulated. This
also controls bleeding after surgery. Repositioning the catheter would not be an option right after
surgery.
C) Blood clots give the client the sensation to urinate when they obstruct the urine outflow;
therefore, irrigation will have to remedy the problem. Deflating and reinflating the balloon is not
an option. The surgeon knows how much pressure is needed to control bleeding after surgery.
The catheter is usually taped to the client's leg after a TURP and is not to be manipulated. This
also controls bleeding after surgery. Repositioning the catheter would not be an option right after
surgery.
D) Blood clots give the client the sensation to urinate when they obstruct the urine outflow;
therefore, irrigation will have to remedy the problem. Deflating and reinflating the balloon is not
an option. The surgeon knows how much pressure is needed to control bleeding after surgery.
The catheter is usually taped to the client's leg after a TURP and is not to be manipulated. This
also controls bleeding after surgery. Repositioning the catheter would not be an option right after
surgery.
Page Ref: 289
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and
caring interventions across the life span for individuals with common alterations in elimination.

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9) A nurse is caring for a client with congestive heart failure. The physician has ordered
propranolol (Inderal) for the client. Which instruction should the nurse include when
administering a beta-adrenergic like propranolol (Inderal) to the client?
A) "This medication must be taken on an empty stomach."
B) "You will need to discontinue the medication when your symptoms subside."
C) "This medication causes constipation. You should take a laxative every day."
D) "It is important to notify your physician if you experience urinary retention."
Answer: D
Explanation: A) A beta-adrenergic blocker such as propranolol can cause urinary retention;
therefore, it would be of the utmost importance to notify one's physician. Clients should always
check with their physician before stopping any medication, because there could be some major
complications. Constipation has been reported from clients taking propranolol, but a laxative
should not be taken every day, as one can become dependent. This medicine should be taken
with food, not on an empty stomach, in order to enhance absorption.
B) A beta-adrenergic blocker such as propranolol can cause urinary retention; therefore, it would
be of the utmost importance to notify one's physician. Clients should always check with their
physician before stopping any medication, because there could be some major complications.
Constipation has been reported from clients taking propranolol, but a laxative should not be
taken every day, as one can become dependent. This medicine should be taken with food, not on
an empty stomach, in order to enhance absorption.
C) A beta-adrenergic blocker such as propranolol can cause urinary retention; therefore, it would
be of the utmost importance to notify one's physician. Clients should always check with their
physician before stopping any medication, because there could be some major complications.
Constipation has been reported from clients taking propranolol, but a laxative should not be
taken every day, as one can become dependent. This medicine should be taken with food, not on
an empty stomach, in order to enhance absorption.
D) A beta-adrenergic blocker such as propranolol can cause urinary retention; therefore, it would
be of the utmost importance to notify one's physician. Clients should always check with their
physician before stopping any medication, because there could be some major complications.
Constipation has been reported from clients taking propranolol, but a laxative should not be
taken every day, as one can become dependent. This medicine should be taken with food, not on
an empty stomach, in order to enhance absorption.
Page Ref: 261
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 8. Compare and contrast common independent and collaborative
interventions for clients with alterations in elimination.

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10) The nurse working on a medical unit is aware that a high pH, or more alkaline urine, could
indicate which condition?
A) Urinary tract infection
B) Diarrhea
C) Respiratory acidosis
D) Metabolic acidosis
Answer: A
Explanation: A) Alkaline urine may indicate a state of alkalosis, a UTI, bacteriuria, antibiotics,
sulfonamides, sodium bicarbonate, acetazolamide, potassium citrate, or a diet high in fruits and
vegetables. More acidic urine (low pH) is found in starvation, with diarrhea, with a diet high in
protein foods or cranberries, in metabolic or respiratory acidosis, and with increased ammonium
chloride and mandelic acid concentrations.
B) Alkaline urine may indicate a state of alkalosis, a UTI, bacteriuria, antibiotics, sulfonamides,
sodium bicarbonate, acetazolamide, potassium citrate, or a diet high in fruits and vegetables.
More acidic urine (low pH) is found in starvation, with diarrhea, with a diet high in protein foods
or cranberries, in metabolic or respiratory acidosis, and with increased ammonium chloride and
mandelic acid concentrations.
C) Alkaline urine may indicate a state of alkalosis, a UTI, bacteriuria, antibiotics, sulfonamides,
sodium bicarbonate, acetazolamide, potassium citrate, or a diet high in fruits and vegetables.
More acidic urine (low pH) is found in starvation, with diarrhea, with a diet high in protein foods
or cranberries, in metabolic or respiratory acidosis, and with increased ammonium chloride and
mandelic acid concentrations.
D) Alkaline urine may indicate a state of alkalosis, a UTI, bacteriuria, antibiotics, sulfonamides,
sodium bicarbonate, acetazolamide, potassium citrate, or a diet high in fruits and vegetables.
More acidic urine (low pH) is found in starvation, with diarrhea, with a diet high in protein foods
or cranberries, in metabolic or respiratory acidosis, and with increased ammonium chloride and
mandelic acid concentrations.
Page Ref: 270
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing Process: Assessment
Learning Outcome: 5. Describe diagnostic and laboratory tests to determine the individual's
elimination status.

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11) The nurse at a health fair is educating clients on risk factors associated with urinary
problems. The nurse is aware that which of the following are modifiable risk factors?
Select all that apply.
A) Age
B) Obesity
C) Urinary tract infections
D) Spina bifida
E) Constipation
Answer: B, C, E
Explanation: A) Obesity and pregnancy are modifiable risk factors for urinary incontinence,
obesity most likely because of the excess force placed on the bladder and pregnancy because of
the weight of the expanding uterus on the bladder. Other modifiable risk factors for loss of
bladder control include urinary tract infections, increased consumption of bladder irritants, and
poor lifestyle habits. Individuals with bowel problems such as constipation are also at higher risk
for developing urinary problems. Older age is a non-modifiable risk factor. The excretory
function of the kidneys diminishes as individuals age, but function usually does not diminish
significantly below normal levels unless a disease process intervenes. Disability and a family
history of incontinence also increase an individual's risk of developing urinary incontinence.
Genetic conditions such as myelomeningocele or spina bifida and conditions associated with
aging such as Parkinson disease can also contribute to urinary problems.
B) Obesity and pregnancy are modifiable risk factors for urinary incontinence, obesity most
likely because of the excess force placed on the bladder and pregnancy because of the weight of
the expanding uterus on the bladder. Other modifiable risk factors for loss of bladder control
include urinary tract infections, increased consumption of bladder irritants, and poor lifestyle
habits. Individuals with bowel problems such as constipation are also at higher risk for
developing urinary problems. Older age is a non-modifiable risk factor. The excretory function
of the kidneys diminishes as individuals age, but function usually does not diminish significantly
below normal levels unless a disease process intervenes. Disability and a family history of
incontinence also increase an individual's risk of developing urinary incontinence. Genetic
conditions such as myelomeningocele or spina bifida and conditions associated with aging such
as Parkinson disease can also contribute to urinary problems.
C) Obesity and pregnancy are modifiable risk factors for urinary incontinence, obesity most
likely because of the excess force placed on the bladder and pregnancy because of the weight of
the expanding uterus on the bladder. Other modifiable risk factors for loss of bladder control
include urinary tract infections, increased consumption of bladder irritants, and poor lifestyle
habits. Individuals with bowel problems such as constipation are also at higher risk for
developing urinary problems. Older age is a non-modifiable risk factor. The excretory function
of the kidneys diminishes as individuals age, but function usually does not diminish significantly
below normal levels unless a disease process intervenes. Disability and a family history of
incontinence also increase an individual's risk of developing urinary incontinence. Genetic
conditions such as myelomeningocele or spina bifida and conditions associated with aging such
as Parkinson disease can also contribute to urinary problems.

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D) Obesity and pregnancy are modifiable risk factors for urinary incontinence, obesity most
likely because of the excess force placed on the bladder and pregnancy because of the weight of
the expanding uterus on the bladder. Other modifiable risk factors for loss of bladder control
include urinary tract infections, increased consumption of bladder irritants, and poor lifestyle
habits. Individuals with bowel problems such as constipation are also at higher risk for
developing urinary problems. Older age is a non-modifiable risk factor. The excretory function
of the kidneys diminishes as individuals age, but function usually does not diminish significantly
below normal levels unless a disease process intervenes. Disability and a family history of
incontinence also increase an individual's risk of developing urinary incontinence. Genetic
conditions such as myelomeningocele or spina bifida and conditions associated with aging such
as Parkinson disease can also contribute to urinary problems.
E) Obesity and pregnancy are modifiable risk factors for urinary incontinence, obesity most
likely because of the excess force placed on the bladder and pregnancy because of the weight of
the expanding uterus on the bladder. Other modifiable risk factors for loss of bladder control
include urinary tract infections, increased consumption of bladder irritants, and poor lifestyle
habits. Individuals with bowel problems such as constipation are also at higher risk for
developing urinary problems. Older age is a non-modifiable risk factor. The excretory function
of the kidneys diminishes as individuals age, but function usually does not diminish significantly
below normal levels unless a disease process intervenes. Disability and a family history of
incontinence also increase an individual's risk of developing urinary incontinence. Genetic
conditions such as myelomeningocele or spina bifida and conditions associated with aging such
as Parkinson disease can also contribute to urinary problems.
Page Ref: 261
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Teaching and Learning
Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and
caring interventions across the life span for individuals with common alterations in elimination.

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12) The nursing instructor conducting a lecture on alterations in urination would identify the
need for further instruction when a student nurse makes which statement?
A) "A client suffering from difficulty or painful urination is experiencing dysuria."
B) "A client who has no urinary output is experiencing anuria."
C) "A client who has a urinary output of 1,300 mL/day is experiencing oliguria."
D) "A client who is up several times at night is experiencing nocturia."
Answer: C
Explanation: A) Oliguria is scant urine; normal urinary output for an adult is less than 1,500 mL
per day, so 1,300 mL output is not oliguria. The other statements are correct.
B) Oliguria is scant urine; normal urinary output for an adult is less than 1,500 mL per day, so
1,300 mL output is not oliguria. The other statements are correct.
C) Oliguria is scant urine; normal urinary output for an adult is less than 1,500 mL per day, so
1,300 mL output is not oliguria. The other statements are correct.
D) Oliguria is scant urine; normal urinary output for an adult is less than 1,500 mL per day, so
1,300 mL output is not oliguria. The other statements are correct.
Page Ref: 264
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Teaching and Learning
Learning Outcome: 1. Summarize the physiology of the renal and gastrointestinal systems
related to elimination.

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13) The charge nurse is observing a newly licensed nurse conduct an abdominal assessment on a
client admitted with an abdominal mass. Which actions observed would indicate to the charge
nurse the need to intervene?
Select all that apply.
A) The newly licensed nurse is performing palpation before auscultation.
B) The newly licensed nurse is performing auscultation before palpation.
C) The newly licensed nurse utilizes inspection, auscultation, percussion, and palpation during
the abdominal assessment of the client.
D) The newly licensed nurse only utilizes inspection, percussion, and palpation during the
abdominal assessment of the client.
E) The newly licensed nurse uses deep palpation when palpating the abdomen.
Answer: A, D, E
Explanation: A) Physical examination of the abdomen in relation to fecal elimination problems
includes inspection, auscultation, percussion, and palpation. Auscultation should precede
palpation, because palpation can alter peristalsis. Never use deep palpation on a client who has
had a pulsatile abdominal mass, renal transplant, or polycystic kidneys, or who is at risk for
hemorrhage.
B) Physical examination of the abdomen in relation to fecal elimination problems includes
inspection, auscultation, percussion, and palpation. Auscultation should precede palpation,
because palpation can alter peristalsis. Never use deep palpation on a client who has had a
pulsatile abdominal mass, renal transplant, or polycystic kidneys, or who is at risk for
hemorrhage.
C) Physical examination of the abdomen in relation to fecal elimination problems includes
inspection, auscultation, percussion, and palpation. Auscultation should precede palpation,
because palpation can alter peristalsis. Never use deep palpation on a client who has had a
pulsatile abdominal mass, renal transplant, or polycystic kidneys, or who is at risk for
hemorrhage.
D) Physical examination of the abdomen in relation to fecal elimination problems includes
inspection, auscultation, percussion, and palpation. Auscultation should precede palpation,
because palpation can alter peristalsis. Never use deep palpation on a client who has had a
pulsatile abdominal mass, renal transplant, or polycystic kidneys, or who is at risk for
hemorrhage.
E) Physical examination of the abdomen in relation to fecal elimination problems includes
inspection, auscultation, percussion, and palpation. Auscultation should precede palpation,
because palpation can alter peristalsis. Never use deep palpation on a client who has had a
pulsatile abdominal mass, renal transplant, or polycystic kidneys, or who is at risk for
hemorrhage.
Page Ref: 268
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Assessment
Learning Outcome: 4. Differentiate common assessment procedures used to examine urinary
and gastrointestinal health across the life span.

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14) The client is experiencing urinary urgency and frequency. Which medication should the
nurse anticipate may be ordered by the physician?
A) Furosemide
B) Bumetanide
C) Oxybutynin
D) Bethanechol chloride
Answer: C
Explanation: A) Oxybutynin is an anticholinergic that reduces urgency and frequency by
blocking muscarinic receptors in the detrusor muscle of the bladder, thereby inhibiting
contractions and increasing storage capacity. The nurse would anticipate an order for
oxybutynin. Furosemide is a diuretic and works in a specific place within the nephron to increase
fluid excretion and prevent fluid reabsorption. Bumetanide is a diuretic and works in a specific
place within the nephron to increase fluid excretion and prevent fluid reabsorption. Bethanechol
chloride is a cholinergic agent that stimulates bladder contraction and facilitates voiding.
B) Oxybutynin is an anticholinergic that reduces urgency and frequency by blocking muscarinic
receptors in the detrusor muscle of the bladder, thereby inhibiting contractions and increasing
storage capacity. The nurse would anticipate an order for oxybutynin. Furosemide is a diuretic
and works in a specific place within the nephron to increase fluid excretion and prevent fluid
reabsorption. Bumetanide is a diuretic and works in a specific place within the nephron to
increase fluid excretion and prevent fluid reabsorption. Bethanechol chloride is a cholinergic
agent that stimulates bladder contraction and facilitates voiding.
C) Oxybutynin is an anticholinergic that reduces urgency and frequency by blocking muscarinic
receptors in the detrusor muscle of the bladder, thereby inhibiting contractions and increasing
storage capacity. The nurse would anticipate an order for oxybutynin. Furosemide is a diuretic
and works in a specific place within the nephron to increase fluid excretion and prevent fluid
reabsorption. Bumetanide is a diuretic and works in a specific place within the nephron to
increase fluid excretion and prevent fluid reabsorption. Bethanechol chloride is a cholinergic
agent that stimulates bladder contraction and facilitates voiding.
D) Oxybutynin is an anticholinergic that reduces urgency and frequency by blocking muscarinic
receptors in the detrusor muscle of the bladder, thereby inhibiting contractions and increasing
storage capacity. The nurse would anticipate an order for oxybutynin. Furosemide is a diuretic
and works in a specific place within the nephron to increase fluid excretion and prevent fluid
reabsorption. Bumetanide is a diuretic and works in a specific place within the nephron to
increase fluid excretion and prevent fluid reabsorption. Bethanechol chloride is a cholinergic
agent that stimulates bladder contraction and facilitates voiding.
Page Ref: 272
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing Process: Implementation
Learning Outcome: 8. Compare and contrast common independent and collaborative
interventions for clients with alterations in elimination.

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Copyright © 2015 Pearson Education, Inc.
Exemplar 5.1 Benign Prostatic Hyperplasia

1) The nurse is caring for a client who was recently diagnosed with benign prostatic hyperplasia
(BPH). The client is being seen in the clinic because of an increase in symptoms. Which
statement by the client would best explain the source of the increased symptoms?
A) "I have decreased oral intake at night."
B) "I recently had a vasectomy."
C) "I am using an over-the-counter cold medication for a cold."
D) "I am taking over-the-counter saw palmetto."
Answer: C
Explanation: A) Use of cold medications can increase symptoms because of their anticholinergic
properties. Use of saw palmetto and decreased oral intake at night may resolve symptoms. A
vasectomy does not affect the symptoms of BPH.
B) Use of cold medications can increase symptoms because of their anticholinergic properties.
Use of saw palmetto and decreased oral intake at night may resolve symptoms. A vasectomy
does not affect the symptoms of BPH.
C) Use of cold medications can increase symptoms because of their anticholinergic properties.
Use of saw palmetto and decreased oral intake at night may resolve symptoms. A vasectomy
does not affect the symptoms of BPH.
D) Use of cold medications can increase symptoms because of their anticholinergic properties.
Use of saw palmetto and decreased oral intake at night may resolve symptoms. A vasectomy
does not affect the symptoms of BPH.
Page Ref: 287
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of benign prostatic hyperplasia.

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2) A nurse educator is teaching a urology unit to a group of nursing students. The educator is
reviewing risk factors for the diagnosis of benign prostatic hyperplasia (BPH). The educator
includes which risk factor to the group?
Select all that apply.
A) Excessive exercise
B) Diet high in meat and fats
C) Diet high in milk
D) Age
E) Race
Answer: B, D, E
Explanation: A) Although the exact cause is unknown, risk factors associated with BPH are
increasing age, men of African-American descent, and a diet high in meat and fat. No link has
been made to milk or exercise.
B) Although the exact cause is unknown, risk factors associated with BPH are increasing age,
men of African-American descent, and a diet high in meat and fat. No link has been made to
milk or exercise.
C) Although the exact cause is unknown, risk factors associated with BPH are increasing age,
men of African-American descent, and a diet high in meat and fat. No link has been made to
milk or exercise.
D) Although the exact cause is unknown, risk factors associated with BPH are increasing age,
men of African-American descent, and a diet high in meat and fat. No link has been made to
milk or exercise.
E) Although the exact cause is unknown, risk factors associated with BPH are increasing age,
men of African-American descent, and a diet high in meat and fat. No link has been made to
milk or exercise.
Page Ref: 285
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 2. Identify risk factors and prevention methods associated with benign
prostatic hyperplasia.

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Copyright © 2015 Pearson Education, Inc.
3) The nurse is caring for a male client of Japanese descent. The client is experiencing urinary
frequency and he asks the nurse if he has benign prostatic hyperplasia (BPH). Which statement
by the nurse is the most appropriate?
A) "No, you are not old enough yet to have the disease."
B) "No, you do not have BPH, as you are of Asian descent."
C) "The tests will determine your diagnosis, but men of Japanese descent are not at high risk for
this disease."
D) "Where did you get an idea like that?"
Answer: C
Explanation: A) The nurse is always honest in replying to a client. The nurse tells the client that
the tests will provide the actual results but that he is in a low-risk category. Telling the client that
he does not have the disease is not wise as, Japanese or not, he could have BPH. Asking a client
where he got that idea is demeaning.
B) The nurse is always honest in replying to a client. The nurse tells the client that the tests will
provide the actual results but that he is in a low-risk category. Telling the client that he does not
have the disease is not wise as, Japanese or not, he could have BPH. Asking a client where he got
that idea is demeaning.
C) The nurse is always honest in replying to a client. The nurse tells the client that the tests will
provide the actual results but that he is in a low-risk category. Telling the client that he does not
have the disease is not wise as, Japanese or not, he could have BPH. Asking a client where he got
that idea is demeaning.
D) The nurse is always honest in replying to a client. The nurse tells the client that the tests will
provide the actual results but that he is in a low-risk category. Telling the client that he does not
have the disease is not wise as, Japanese or not, he could have BPH. Asking a client where he got
that idea is demeaning.
Page Ref: 285
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with benign prostatic hyperplasia.

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4) A client is being seen in the clinic for a follow-up visit and progress check. The client was
recently diagnosed with benign prostatic hyperplasia (BPH). The nurse is planning care and
selects Urinary Retention as a nursing diagnosis based on which client statement?
A) "I am aware that I need to report no urine output."
B) "I need to drink 20 ounces of water at each meal."
C) "I have stopped taking over-the-counter decongestants for my allergies."
D) "I use the double-voiding technique."
Answer: B
Explanation: A) A single intake of a large volume of fluid results in rapid bladder filling and a
risk for retention. Over-the-counter decongestants increase the risk for urinary retention. Clients
are taught the double-voiding technique to help avoid urinary retention. No urine output is a sign
that requires immediate medical attention, not just the diagnosis Impaired Urinary Retention.
B) A single intake of a large volume of fluid results in rapid bladder filling and a risk for
retention. Over-the-counter decongestants increase the risk for urinary retention. Clients are
taught the double-voiding technique to help avoid urinary retention. No urine output is a sign that
requires immediate medical attention, not just the diagnosis Impaired Urinary Retention.
C) A single intake of a large volume of fluid results in rapid bladder filling and a risk for
retention. Over-the-counter decongestants increase the risk for urinary retention. Clients are
taught the double-voiding technique to help avoid urinary retention. No urine output is a sign that
requires immediate medical attention, not just the diagnosis Impaired Urinary Retention.
D) A single intake of a large volume of fluid results in rapid bladder filling and a risk for
retention. Over-the-counter decongestants increase the risk for urinary retention. Clients are
taught the double-voiding technique to help avoid urinary retention. No urine output is a sign that
requires immediate medical attention, not just the diagnosis Impaired Urinary Retention.
Page Ref: 288
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
benign prostatic hyperplasia.

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5) A client is recovering from prostate surgery on a medical-surgical nursing unit. The client will
be ready for discharge within the next few days. Which point would the nurse want to teach the
client and family prior to discharge?
A) The client should not drive for 6 weeks after surgery.
B) The client should call the doctor immediately for any pain.
C) The client should increase the fiber in his diet.
D) The client should avoid heavy lifting for 2 weeks after surgery.
Answer: C
Explanation: A) The client should be encouraged to increase the fiber in his diet, as straining for
bowel movements after surgery can cause increased pressure in the prostate area. The client and
family are taught good dietary habits to keep bowel movements regular and soft. The client may
not drive for 2 weeks after surgery. The client is taught to avoid heavy lifting for 4-8 weeks after
discharge and to call the doctor for severe abdominal or chest pain.
B) The client should be encouraged to increase the fiber in his diet, as straining for bowel
movements after surgery can cause increased pressure in the prostate area. The client and family
are taught good dietary habits to keep bowel movements regular and soft. The client may not
drive for 2 weeks after surgery. The client is taught to avoid heavy lifting for 4-8 weeks after
discharge and to call the doctor for severe abdominal or chest pain.
C) The client should be encouraged to increase the fiber in his diet, as straining for bowel
movements after surgery can cause increased pressure in the prostate area. The client and family
are taught good dietary habits to keep bowel movements regular and soft. The client may not
drive for 2 weeks after surgery. The client is taught to avoid heavy lifting for 4-8 weeks after
discharge and to call the doctor for severe abdominal or chest pain.
D) The client should be encouraged to increase the fiber in his diet, as straining for bowel
movements after surgery can cause increased pressure in the prostate area. The client and family
are taught good dietary habits to keep bowel movements regular and soft. The client may not
drive for 2 weeks after surgery. The client is taught to avoid heavy lifting for 4-8 weeks after
discharge and to call the doctor for severe abdominal or chest pain.
Page Ref: 290
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with benign prostatic
hyperplasia and his family in collaboration with other members of the healthcare team.

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Copyright © 2015 Pearson Education, Inc.
6) A client is recovering from minimally invasive surgery due to a diagnosis of benign prostatic
hyperplasia (BPH). The client is being transferred to a medical-surgical unit. After assessing the
client, the nurse expects which outcome for this client?
A) Bowel continence
B) Absence of pain
C) No postoperative treatment
D) Urinary continence
Answer: D
Explanation: A) After surgery and removal of the catheter, the client should return to urinary
continence as expected. The client will need postoperative teaching and will experience some
amount of discomfort. Most clients, due to pain and swelling in the area, will have problems with
constipation at first.
B) After surgery and removal of the catheter, the client should return to urinary continence as
expected. The client will need postoperative teaching and will experience some amount of
discomfort. Most clients, due to pain and swelling in the area, will have problems with
constipation at first.
C) After surgery and removal of the catheter, the client should return to urinary continence as
expected. The client will need postoperative teaching and will experience some amount of
discomfort. Most clients, due to pain and swelling in the area, will have problems with
constipation at first.
D) After surgery and removal of the catheter, the client should return to urinary continence as
expected. The client will need postoperative teaching and will experience some amount of
discomfort. Most clients, due to pain and swelling in the area, will have problems with
constipation at first.
Page Ref: 290
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 7. Evaluate expected outcomes for an individual with benign prostatic
hyperplasia.

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7) The nurse and doctor are discussing treatment options for a client diagnosed with benign
prostatic hypertrophy (BPH) with the client and his wife. The client says, "I would like to try an
alternative therapy before turning to traditional treatment.” The nurse is aware that which of the
following is an alternative therapy?
A) Balloon uretoplasty
B) Treatment with dutasteride (Avodart)
C) Laser surgery
D) Use of phytotherapy
Answer: D
Explanation: A) Phytotherapy includes use of barks and roots of the saw palmetto berry or
Echinacea, among others. The mechanism of action is unknown, but clients do experience relief.
Laser surgery, dutasteride (Avodart), and balloon uretoplasty are conventional methods of
treating BPH.
B) Phytotherapy includes use of barks and roots of the saw palmetto berry or Echinacea, among
others. The mechanism of action is unknown, but clients do experience relief. Laser surgery,
dutasteride (Avodart), and balloon uretoplasty are conventional methods of treating BPH.
C) Phytotherapy includes use of barks and roots of the saw palmetto berry or Echinacea, among
others. The mechanism of action is unknown, but clients do experience relief. Laser surgery,
dutasteride (Avodart), and balloon uretoplasty are conventional methods of treating BPH.
D) Phytotherapy includes use of barks and roots of the saw palmetto berry or Echinacea, among
others. The mechanism of action is unknown, but clients do experience relief. Laser surgery,
dutasteride (Avodart), and balloon uretoplasty are conventional methods of treating BPH.
Page Ref: 287
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with benign prostatic hyperplasia.

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8) A 58-year-old male presents to the urologist with complaints of getting up to urinate several
times a night and difficulty starting a stream of urine. After medical testing is completed, a
diagnosis of benign prostatic hyperplasia (BPH) is made. Which of the following statements by
the client indicates the need for additional teaching?
A) "Alpha blockers can be used to control my symptoms."
B) "I know I will get cancer of the prostate because of this."
C) "As my condition progresses, I may need to consider surgical management."
D) "There are nonsurgical treatment options available."
Answer: B
Explanation: A) This is a benign condition that does not necessarily progress to cancer. It is
caused by an increase in size of the prostate gland and is seen in older males. There are
nonsurgical treatments available, such as medication to shrink the gland or a surgical resection.
Alpha blockers will help control the symptoms.
B) This is a benign condition that does not necessarily progress to cancer. It is caused by an
increase in size of the prostate gland and is seen in older males. There are nonsurgical treatments
available, such as medication to shrink the gland or a surgical resection. Alpha blockers will help
control the symptoms.
C) This is a benign condition that does not necessarily progress to cancer. It is caused by an
increase in size of the prostate gland and is seen in older males. There are nonsurgical treatments
available, such as medication to shrink the gland or a surgical resection. Alpha blockers will help
control the symptoms.
D) This is a benign condition that does not necessarily progress to cancer. It is caused by an
increase in size of the prostate gland and is seen in older males. There are nonsurgical treatments
available, such as medication to shrink the gland or a surgical resection. Alpha blockers will help
control the symptoms.
Page Ref: 285
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with benign prostatic
hyperplasia and his family in collaboration with other members of the healthcare team.

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Copyright © 2015 Pearson Education, Inc.
9) A client is scheduled for BPH surgery and appears confused about the surgery and possible
outcome. What topics should the nurse include in a discussion with the client?
Select all that apply.
A) Function of the prostate gland and its exact location
B) BPH diet
C) Expected surgical approach
D) Scope of preoperative activities and postoperative conditions
E) Presence of a urinary catheter
Answer: A, C, D, E
Explanation: A) Lack of knowledge about the prostate is confusing to many men. There is no
specific BPH diet. Clients may also be confused about the surgical approach because of the
several different methods. Understanding the scope of preoperative activities and postoperative
conditions increases client cooperation with postoperative care. Explain to the client that he will
have a urinary catheter when he returns from surgery.
B) Lack of knowledge about the prostate is confusing to many men. There is no specific BPH
diet. Clients may also be confused about the surgical approach because of the several different
methods. Understanding the scope of preoperative activities and postoperative conditions
increases client cooperation with postoperative care. Explain to the client that he will have a
urinary catheter when he returns from surgery.
C) Lack of knowledge about the prostate is confusing to many men. There is no specific BPH
diet. Clients may also be confused about the surgical approach because of the several different
methods. Understanding the scope of preoperative activities and postoperative conditions
increases client cooperation with postoperative care. Explain to the client that he will have a
urinary catheter when he returns from surgery.
D) Lack of knowledge about the prostate is confusing to many men. There is no specific BPH
diet. Clients may also be confused about the surgical approach because of the several different
methods. Understanding the scope of preoperative activities and postoperative conditions
increases client cooperation with postoperative care. Explain to the client that he will have a
urinary catheter when he returns from surgery.
E) Lack of knowledge about the prostate is confusing to many men. There is no specific BPH
diet. Clients may also be confused about the surgical approach because of the several different
methods. Understanding the scope of preoperative activities and postoperative conditions
increases client cooperation with postoperative care. Explain to the client that he will have a
urinary catheter when he returns from surgery.
Page Ref: 288
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
Nursing Process: Communication and Documentation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with benign prostatic hyperplasia.

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10) A client diagnosed with benign prostatic hyperplasia is being discharged. The nurse is
reviewing discharge instructions with the client. Which statements made by the client indicate an
understanding of the instructions?
Select all that apply.
A) "I should urinate at first urge."
B) "I should avoid alcohol and caffeine."
C) "I should avoid over-the-counter cold and sinus medications that contain decongestants or
antihistamines."
D) "I should still be able to enjoy a few beers every evening."
E) "When I need to, I can still take the over-the-counter decongestant I have at home."
Answer: A, B, C
Explanation: A) Clients with mild benign prostatic hyperplasia (BPH) may control symptoms of
mild BPH with lifestyle changes, such as urinating at first urge, avoiding fluids within 2 hours of
bedtime, regular exercise, stress reduction, and avoiding alcohol and caffeine. Urinary retention
in men with BPH can be precipitated by several classes of medications, including those with
anticholinergic properties and over-the-counter medications for the common cold, such as
decongestants.
B) Clients with mild benign prostatic hyperplasia (BPH) may control symptoms of mild BPH
with lifestyle changes, such as urinating at first urge, avoiding fluids within 2 hours of bedtime,
regular exercise, stress reduction, and avoiding alcohol and caffeine. Urinary retention in men
with BPH can be precipitated by several classes of medications, including those with
anticholinergic properties and over-the-counter medications for the common cold, such as
decongestants.
C) Clients with mild benign prostatic hyperplasia (BPH) may control symptoms of mild BPH
with lifestyle changes, such as urinating at first urge, avoiding fluids within 2 hours of bedtime,
regular exercise, stress reduction, and avoiding alcohol and caffeine. Urinary retention in men
with BPH can be precipitated by several classes of medications, including those with
anticholinergic properties and over-the-counter medications for the common cold, such as
decongestants.
D) Clients with mild benign prostatic hyperplasia (BPH) may control symptoms of mild BPH
with lifestyle changes, such as urinating at first urge, avoiding fluids within 2 hours of bedtime,
regular exercise, stress reduction, and avoiding alcohol and caffeine. Urinary retention in men
with BPH can be precipitated by several classes of medications, including those with
anticholinergic properties and over-the-counter medications for the common cold, such as
decongestants.
E) Clients with mild benign prostatic hyperplasia (BPH) may control symptoms of mild BPH
with lifestyle changes, such as urinating at first urge, avoiding fluids within 2 hours of bedtime,
regular exercise, stress reduction, and avoiding alcohol and caffeine. Urinary retention in men
with BPH can be precipitated by several classes of medications, including those with
anticholinergic properties and over-the-counter medications for the common cold, such as
decongestants.
Page Ref: 290
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Evaluation
Learning Outcome: 2. Identify risk factors and prevention methods associated with benign
prostatic hyperplasia.
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11) The client admitted with benign prostatic hyperplasia (BPH) is prescribed an alpha-
adrenergic blocker. The nurse is aware that which alpha-adrenergic blocker may have caused an
adverse reaction known as first-dose phenomenon?
A) Prazosin (Minipress)
B) Doxazosin (Cardura)
C) Dutasteride (Avodart)
D) Finasteride (Proscar)
Answer: A
Explanation: A) The medication prazosin (Minipress) is an alpha-adrenergic blocker that may
cause first-dose phenomenon (severe hypotension and syncope) and tachycardia. The medication
doxazosin (Cardura) is an alpha-adrenergic blocker that may cause orthostatic hypotension,
headaches, or dizziness. The medication dutasteride (Avodart) is a 5-alpha reductase inhibitor
that may cause sexual dysfunction, decreased libido, or decreased ejaculate volumes. The
medication finasteride (Proscar) is a 5-alpha reductase inhibitor that has no serious adverse
reactions.
B) The medication prazosin (Minipress) is an alpha-adrenergic blocker that may cause first-dose
phenomenon (severe hypotension and syncope) and tachycardia. The medication doxazosin
(Cardura) is an alpha-adrenergic blocker that may cause orthostatic hypotension, headaches, or
dizziness. The medication dutasteride (Avodart) is a 5-alpha reductase inhibitor that may cause
sexual dysfunction, decreased libido, or decreased ejaculate volumes. The medication finasteride
(Proscar) is a 5-alpha reductase inhibitor that has no serious adverse reactions.
C) The medication prazosin (Minipress) is an alpha-adrenergic blocker that may cause first-dose
phenomenon (severe hypotension and syncope) and tachycardia. The medication doxazosin
(Cardura) is an alpha-adrenergic blocker that may cause orthostatic hypotension, headaches, or
dizziness. The medication dutasteride (Avodart) is a 5-alpha reductase inhibitor that may cause
sexual dysfunction, decreased libido, or decreased ejaculate volumes. The medication finasteride
(Proscar) is a 5-alpha reductase inhibitor that has no serious adverse reactions.
D) The medication prazosin (Minipress) is an alpha-adrenergic blocker that may cause first-dose
phenomenon (severe hypotension and syncope) and tachycardia. The medication doxazosin
(Cardura) is an alpha-adrenergic blocker that may cause orthostatic hypotension, headaches, or
dizziness. The medication dutasteride (Avodart) is a 5-alpha reductase inhibitor that may cause
sexual dysfunction, decreased libido, or decreased ejaculate volumes. The medication finasteride
(Proscar) is a 5-alpha reductase inhibitor that has no serious adverse reactions.
Page Ref: 287
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing Process: Assessment
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with benign prostatic hyperplasia.

27
Copyright © 2015 Pearson Education, Inc.
12) The nurse determines that which goal is most appropriate for a client with mild benign
prostatic hyperplasia (BPH) who is experiencing urinary retention?
A) The client will increase fluid intake to at least 2-3 liters daily
B) The client lists over-the-counter medications to be avoided.
C) The client will voice an understanding of the importance of the use of antiembolic stockings
and compression devices.
D) The client will use a T-binder or scrotal support properly.
Answer: B
Explanation: A) Avoiding over-the-counter medications can lessen or prevent the symptoms
associated with mild benign prostatic hyperplasia (BPH). An increased fluid intake can assist in
preventing burning on urination after catheter removal and reduces the risk of a urinary tract
infection. There is no indication that this client had surgery or had a catheter placed. The use of
antiembolic stockings and compression devices reduces the risk of developing a
thromboembolism. There is no indication that this client had surgery or is at risk for developing a
thromboembolism. The use of a T-binder or scrotal support is for those clients that have
undergone surgery and are in need of scrotal support and support of the surgical dressing. There
is no indication that this client had surgery or had a catheter placed.
B) Avoiding over-the-counter medications can lessen or prevent the symptoms associated with
mild benign prostatic hyperplasia (BPH). An increased fluid intake can assist in preventing
burning on urination after catheter removal and reduces the risk of a urinary tract infection.
There is no indication that this client had surgery or had a catheter placed. The use of
antiembolic stockings and compression devices reduces the risk of developing a
thromboembolism. There is no indication that this client had surgery or is at risk for developing a
thromboembolism. The use of a T-binder or scrotal support is for those clients that have
undergone surgery and are in need of scrotal support and support of the surgical dressing. There
is no indication that this client had surgery or had a catheter placed.
C) Avoiding over-the-counter medications can lessen or prevent the symptoms associated with
mild benign prostatic hyperplasia (BPH). An increased fluid intake can assist in preventing
burning on urination after catheter removal and reduces the risk of a urinary tract infection.
There is no indication that this client had surgery or had a catheter placed. The use of
antiembolic stockings and compression devices reduces the risk of developing a
thromboembolism. There is no indication that this client had surgery or is at risk for developing a
thromboembolism. The use of a T-binder or scrotal support is for those clients that have
undergone surgery and are in need of scrotal support and support of the surgical dressing. There
is no indication that this client had surgery or had a catheter placed.

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D) Avoiding over-the-counter medications can lessen or prevent the symptoms associated with
mild benign prostatic hyperplasia (BPH). An increased fluid intake can assist in preventing
burning on urination after catheter removal and reduces the risk of a urinary tract infection.
There is no indication that this client had surgery or had a catheter placed. The use of
antiembolic stockings and compression devices reduces the risk of developing a
thromboembolism. There is no indication that this client had surgery or is at risk for developing a
thromboembolism. The use of a T-binder or scrotal support is for those clients that have
undergone surgery and are in need of scrotal support and support of the surgical dressing. There
is no indication that this client had surgery or had a catheter placed.
Page Ref: 288
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing Process: Planning
Learning Outcome: 7. Evaluate expected outcomes for an individual with benign prostatic
hyperplasia.

13) A client was admitted with benign prostatic hyperplasia (BPH). The client's primary concern
is burning and difficulty when urinating. Based on the findings, the nurse formulating the plan of
care would be aware that which of the following is the priority nursing diagnosis?
A) Fluid Volume Overload
B) Fluid Volume Deficit
C) Acute Pain
D) Deficient Knowledge
Answer: C
Explanation: A) The patient presents with burning on urination and difficulty urinating. The
burning indicates the patient is experiencing pain and would indicate a priority nursing diagnosis
of acute pain. There is no evidence of fluid volume overload, fluid volume deficit, or knowledge
deficit.
B) The patient presents with burning on urination and difficulty urinating. The burning indicates
the patient is experiencing pain and would indicate a priority nursing diagnosis of acute pain.
There is no evidence of fluid volume overload, fluid volume deficit, or knowledge deficit.
C) The patient presents with burning on urination and difficulty urinating. The burning indicates
the patient is experiencing pain and would indicate a priority nursing diagnosis of acute pain.
There is no evidence of fluid volume overload, fluid volume deficit, or knowledge deficit.
D) The patient presents with burning on urination and difficulty urinating. The burning indicates
the patient is experiencing pain and would indicate a priority nursing diagnosis of acute pain.
There is no evidence of fluid volume overload, fluid volume deficit, or knowledge deficit.
Page Ref: 288
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Planning
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
benign prostatic hyperplasia.

29
Copyright © 2015 Pearson Education, Inc.
Exemplar 5.2 Bladder Incontinence and Retention

1) The nurse is caring for a client with a history of stress incontinence. Which findings would the
nurse expect to assess in this client?
Select all that apply.
A) The leakage of urine occurs when the client is talking.
B) The leakage of urine occurs when the client coughs.
C) The leakage of urine occurs when the client laughs.
D) The skin of the client is clear, without discoloration.
E) The client is wearing cotton undergarments.
Answer: B, C
Explanation: A) Stress incontinence involves a small leakage of urine when a client laughs,
coughs, or lifts something heavy, not if a client just carries on a conversation. A client with
incontinence would wear some kind of undergarment pad. Cotton undergarments alone would
not provide protection for catching the urine. If the client has been experiencing incontinence,
the nurse might expect to see the skin inflamed and irritated because urine is very irritating to the
skin.
B) Stress incontinence involves a small leakage of urine when a client laughs, coughs, or lifts
something heavy, not if a client just carries on a conversation. A client with incontinence would
wear some kind of undergarment pad. Cotton undergarments alone would not provide protection
for catching the urine. If the client has been experiencing incontinence, the nurse might expect to
see the skin inflamed and irritated because urine is very irritating to the skin.
C) Stress incontinence involves a small leakage of urine when a client laughs, coughs, or lifts
something heavy, not if a client just carries on a conversation. A client with incontinence would
wear some kind of undergarment pad. Cotton undergarments alone would not provide protection
for catching the urine. If the client has been experiencing incontinence, the nurse might expect to
see the skin inflamed and irritated because urine is very irritating to the skin.
D) Stress incontinence involves a small leakage of urine when a client laughs, coughs, or lifts
something heavy, not if a client just carries on a conversation. A client with incontinence would
wear some kind of undergarment pad. Cotton undergarments alone would not provide protection
for catching the urine. If the client has been experiencing incontinence, the nurse might expect to
see the skin inflamed and irritated because urine is very irritating to the skin.
E) Stress incontinence involves a small leakage of urine when a client laughs, coughs, or lifts
something heavy, not if a client just carries on a conversation. A client with incontinence would
wear some kind of undergarment pad. Cotton undergarments alone would not provide protection
for catching the urine. If the client has been experiencing incontinence, the nurse might expect to
see the skin inflamed and irritated because urine is very irritating to the skin.
Page Ref: 294
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of bladder incontinence and retention.

30
Copyright © 2015 Pearson Education, Inc.
2) A client with urinary incontinence asks the nurse what may have caused this condition. Which
client statement leads the nurse to believe education has not been effective?
A) "Relaxation of pelvic muscles may be a factor in incontinence."
B) "Reduced urethral resistance can be a cause of incontinence."
C) "Incontinence is normal with aging."
D) "A disturbance of my bladder is a factor in the development of incontinence."
Answer: C
Explanation: A) Incontinence is not a normal result of aging. A disturbance of the bladder,
relaxation of the pelvic muscles, and reduced urethral resistance are all potential factors in the
development of incontinence.
B) Incontinence is not a normal result of aging. A disturbance of the bladder, relaxation of the
pelvic muscles, and reduced urethral resistance are all potential factors in the development of
incontinence.
C) Incontinence is not a normal result of aging. A disturbance of the bladder, relaxation of the
pelvic muscles, and reduced urethral resistance are all potential factors in the development of
incontinence.
D) Incontinence is not a normal result of aging. A disturbance of the bladder, relaxation of the
pelvic muscles, and reduced urethral resistance are all potential factors in the development of
incontinence.
Page Ref: 293
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 2. Identify risk factors and prevention methods associated with bladder
incontinence and retention.

31
Copyright © 2015 Pearson Education, Inc.
3) The nurse is attempting to place a urinary catheter in a 96-year-old female client. The nurse is
unable to visualize the client's urinary meatus. An alternate position to facilitate the insertion of
the catheter would be:
A) Side-lying, lifting up the buttock.
B) Supine, with the HOB elevated at 30°.
C) Supine, with the head of bed (HOB) elevated at 45°.
D) Supine, with the bed flat, legs bent and apart in stirrups.
Answer: A
Explanation: A) Because of estrogen-mediated changes in the perineal area of postmenopausal
women, the urinary meatus may be very difficult to visualize. The side-lying position, lifting up
the buttock, is an alternative that provides better visualization of the urinary meatus. The supine
position, regardless of the leg position or height of the bed, would not increase the visualization
of the urinary meatus because it is more distal from the changes in the perineal area.
B) Because of estrogen-mediated changes in the perineal area of postmenopausal women, the
urinary meatus may be very difficult to visualize. The side-lying position, lifting up the buttock,
is an alternative that provides better visualization of the urinary meatus. The supine position,
regardless of the leg position or height of the bed, would not increase the visualization of the
urinary meatus because it is more distal from the changes in the perineal area.
C) Because of estrogen-mediated changes in the perineal area of postmenopausal women, the
urinary meatus may be very difficult to visualize. The side-lying position, lifting up the buttock,
is an alternative that provides better visualization of the urinary meatus. The supine position,
regardless of the leg position or height of the bed, would not increase the visualization of the
urinary meatus because it is more distal from the changes in the perineal area.
D) Because of estrogen-mediated changes in the perineal area of postmenopausal women, the
urinary meatus may be very difficult to visualize. The side-lying position, lifting up the buttock,
is an alternative that provides better visualization of the urinary meatus. The supine position,
regardless of the leg position or height of the bed, would not increase the visualization of the
urinary meatus because it is more distal from the changes in the perineal area.
Page Ref: 269
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with bladder incontinence and retention.

32
Copyright © 2015 Pearson Education, Inc.
4) The nurse is caring for a client with a retention catheter. The nurse finds that the drainage bag
is lying on the floor when she enters the room to assess the client. Which nursing diagnosis
would be appropriate for this client?
A) Urinary Incontinence related to an obstruction
B) Risk for Impaired Skin Integrity related to catheter placement
C) Risk for Infection related to improper handling
D) Self-Care Deficit related to presence of a retention catheter
Answer: C
Explanation: A) The floor is the dirtiest place in any establishment, so the drainage device
should never be placed on the floor. There is a possibility of skin impairment with a catheter, but
the emphasis here is on where the drainage bag was found. Even with a catheter in place, a client
can still administer self-care; the catheter does not restrict one from practicing basic hygiene.
The client may need some assistance. The placement of a catheter prevents incontinence; it does
not add to it. Placement of the catheter ensures flow, not obstruction.
B) The floor is the dirtiest place in any establishment, so the drainage device should never be
placed on the floor. There is a possibility of skin impairment with a catheter, but the emphasis
here is on where the drainage bag was found. Even with a catheter in place, a client can still
administer self-care; the catheter does not restrict one from practicing basic hygiene. The client
may need some assistance. The placement of a catheter prevents incontinence; it does not add to
it. Placement of the catheter ensures flow, not obstruction.
C) The floor is the dirtiest place in any establishment, so the drainage device should never be
placed on the floor. There is a possibility of skin impairment with a catheter, but the emphasis
here is on where the drainage bag was found. Even with a catheter in place, a client can still
administer self-care; the catheter does not restrict one from practicing basic hygiene. The client
may need some assistance. The placement of a catheter prevents incontinence; it does not add to
it. Placement of the catheter ensures flow, not obstruction.
D) The floor is the dirtiest place in any establishment, so the drainage device should never be
placed on the floor. There is a possibility of skin impairment with a catheter, but the emphasis
here is on where the drainage bag was found. Even with a catheter in place, a client can still
administer self-care; the catheter does not restrict one from practicing basic hygiene. The client
may need some assistance. The placement of a catheter prevents incontinence; it does not add to
it. Placement of the catheter ensures flow, not obstruction.
Page Ref: 259, 300
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
bladder incontinence and retention.

33
Copyright © 2015 Pearson Education, Inc.
5) The nurse is caring for a client who will be discharged with an indwelling catheter. The nurse
has provided education to the client and family in regards to catheter care once the client is
discharged. Which actions by the client and family demonstrate that they understand correct
technique for caring for an indwelling catheter?
A) The client hangs the drainage bag on the towel rod.
B) The client takes a shower each day instead of taking a tub bath.
C) The client will restrict the amounts of fluids per day.
D) The client empties the drainage bag twice a day.
Answer: B
Explanation: A) The client should take a shower rather than a tub bath because sitting in a tub
allows bacteria to easily access the urinary tract. The drainage bag should be emptied regularly,
not just once a day but at least three times a day. Hanging the drainage bag on the towel rod is
too high. The drainage bag should be hung below the bladder. Adequate amounts of fluids
should be consumed to help prevent sediments and infections.
B) The client should take a shower rather than a tub bath because sitting in a tub allows bacteria
to easily access the urinary tract. The drainage bag should be emptied regularly, not just once a
day but at least three times a day. Hanging the drainage bag on the towel rod is too high. The
drainage bag should be hung below the bladder. Adequate amounts of fluids should be consumed
to help prevent sediments and infections.
C) The client should take a shower rather than a tub bath because sitting in a tub allows bacteria
to easily access the urinary tract. The drainage bag should be emptied regularly, not just once a
day but at least three times a day. Hanging the drainage bag on the towel rod is too high. The
drainage bag should be hung below the bladder. Adequate amounts of fluids should be consumed
to help prevent sediments and infections.
D) The client should take a shower rather than a tub bath because sitting in a tub allows bacteria
to easily access the urinary tract. The drainage bag should be emptied regularly, not just once a
day but at least three times a day. Hanging the drainage bag on the towel rod is too high. The
drainage bag should be hung below the bladder. Adequate amounts of fluids should be consumed
to help prevent sediments and infections.
Page Ref: 259, 300
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with bladder incontinence or
retention and his or her family in collaboration with other members of the healthcare team.

34
Copyright © 2015 Pearson Education, Inc.
6) The nurse is working in a urology clinic. The nurse has just seen a client with stress urinary
incontinence. The nurse has chosen the diagnosis of Stress Urinary Incontinence related to
sphincter incompetence. Which is the desired outcome for a client with this diagnosis?
A) The client will stop the flow of urine when voiding.
B) The client will improve her incontinence within 1 month.
C) The client will empty her bladder every time she voids.
D) The client will perform 4-5 squeezes (Kegel exercises) for 10-15 seconds.
Answer: D
Explanation: A) Performing 4-5 squeezes for 10-15 seconds is the goal to start with when
teaching a client Kegel exercises, which are used for stress and urge incontinence. Emptying the
bladder completely every time she voids would not be realistic in the beginning. This will take
time. Improved continence takes 3-6 months, so 1 month is not a realistic goal. Clients are not
instructed to stop the flow of urine when voiding, because this could lead to retention.
B) Performing 4-5 squeezes for 10-15 seconds is the goal to start with when teaching a client
Kegel exercises, which are used for stress and urge incontinence. Emptying the bladder
completely every time she voids would not be realistic in the beginning. This will take time.
Improved continence takes 3-6 months, so 1 month is not a realistic goal. Clients are not
instructed to stop the flow of urine when voiding, because this could lead to retention.
C) Performing 4-5 squeezes for 10-15 seconds is the goal to start with when teaching a client
Kegel exercises, which are used for stress and urge incontinence. Emptying the bladder
completely every time she voids would not be realistic in the beginning. This will take time.
Improved continence takes 3-6 months, so 1 month is not a realistic goal. Clients are not
instructed to stop the flow of urine when voiding, because this could lead to retention.
D) Performing 4-5 squeezes for 10-15 seconds is the goal to start with when teaching a client
Kegel exercises, which are used for stress and urge incontinence. Emptying the bladder
completely every time she voids would not be realistic in the beginning. This will take time.
Improved continence takes 3-6 months, so 1 month is not a realistic goal. Clients are not
instructed to stop the flow of urine when voiding, because this could lead to retention.
Page Ref: 288
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 7. Evaluate expected outcomes for an individual with bladder incontinence
or retention.

35
Copyright © 2015 Pearson Education, Inc.
7) The nurse is caring for a client with a history of chronic urinary tract infections. The nurse has
chosen a diagnosis of Urinary Retention related to scarring from repeat urinary tract infections as
evidenced by a bladder scan. Based on the client's presentation, what would the nurse anticipate
the physician to order?
A) Antibiotic therapy
B) An anticholinergic medication
C) Intermittent straight catheterization
D) Removal of bladder stones
Answer: C
Explanation: A) The doctor may order straight catheterization so the client can be taught to self-
catheterize and manage the problem at home. Anticholinergic medications can cause urinary
retention. Bladder stones are not the problem; scarring is. Antibiotic therapy is not indicated, as
the client does not have an infection now.
B) The doctor may order straight catheterization so the client can be taught to self-catheterize
and manage the problem at home. Anticholinergic medications can cause urinary retention.
Bladder stones are not the problem; scarring is. Antibiotic therapy is not indicated, as the client
does not have an infection now.
C) The doctor may order straight catheterization so the client can be taught to self-catheterize
and manage the problem at home. Anticholinergic medications can cause urinary retention.
Bladder stones are not the problem; scarring is. Antibiotic therapy is not indicated, as the client
does not have an infection now.
D) The doctor may order straight catheterization so the client can be taught to self-catheterize
and manage the problem at home. Anticholinergic medications can cause urinary retention.
Bladder stones are not the problem; scarring is. Antibiotic therapy is not indicated, as the client
does not have an infection now.
Page Ref: 297
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with bladder incontinence or retention.

36
Copyright © 2015 Pearson Education, Inc.
8) The nurse is assessing a 63-year-old female client in a urology clinic. The client reports that
she has been having "accidents." She expresses her frustration about this normal part of aging.
Which statement by the nurse will be most correct at this time?
A) "Incontinence is not a normal part of aging. Tell me more about the incontinence you are
experiencing."
B) "You may need to have surgery to manage this problem."
C) "I understand you are frustrated about this occurrence."
D) "Unfortunately, aging and incontinence go hand in hand."
Answer: A
Explanation: A) As the body ages, there are anatomical changes that make the body increasingly
likely to experience urinary incontinence. Still, urinary incontinence is not a normal part of aging
and it would be appropriate to expand upon the situation. Telling the client you understand does
not provide empathy. It is beyond the nurse's scope of practice to recommend surgery to the
client.
B) As the body ages, there are anatomical changes that make the body increasingly likely to
experience urinary incontinence. Still, urinary incontinence is not a normal part of aging and it
would be appropriate to expand upon the situation. Telling the client you understand does not
provide empathy. It is beyond the nurse's scope of practice to recommend surgery to the client.
C) As the body ages, there are anatomical changes that make the body increasingly likely to
experience urinary incontinence. Still, urinary incontinence is not a normal part of aging and it
would be appropriate to expand upon the situation. Telling the client you understand does not
provide empathy. It is beyond the nurse's scope of practice to recommend surgery to the client.
D) As the body ages, there are anatomical changes that make the body increasingly likely to
experience urinary incontinence. Still, urinary incontinence is not a normal part of aging and it
would be appropriate to expand upon the situation. Telling the client you understand does not
provide empathy. It is beyond the nurse's scope of practice to recommend surgery to the client.
Page Ref: 293
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with bladder incontinence or
retention and his or her family in collaboration with other members of the healthcare team.

37
Copyright © 2015 Pearson Education, Inc.
9) You are providing training for the staff of a skilled care facility and want to include
information on functional incontinence. What are some risk factors for institutional clients?
Select all that apply.
A) Limited mobility
B) Impaired vision
C) Lack of access to facilities
D) Dementia
E) Depression
Answer: A, B, C, D
Explanation: A) An immobilized client may wet the bed if a call light is not within reach; a
client with Alzheimer disease may perceive the urge to void but be unable to interpret its
meaning or respond by seeking a bathroom. A client with impaired vision may not be able to find
the bathroom. Minimal facilities can create problems in urinary control. Depression is not
usually related to incontinence.
B) An immobilized client may wet the bed if a call light is not within reach; a client with
Alzheimer disease may perceive the urge to void but be unable to interpret its meaning or
respond by seeking a bathroom. A client with impaired vision may not be able to find the
bathroom. Minimal facilities can create problems in urinary control. Depression is not usually
related to incontinence.
C) An immobilized client may wet the bed if a call light is not within reach; a client with
Alzheimer disease may perceive the urge to void but be unable to interpret its meaning or
respond by seeking a bathroom. A client with impaired vision may not be able to find the
bathroom. Minimal facilities can create problems in urinary control. Depression is not usually
related to incontinence.
D) An immobilized client may wet the bed if a call light is not within reach; a client with
Alzheimer disease may perceive the urge to void but be unable to interpret its meaning or
respond by seeking a bathroom. A client with impaired vision may not be able to find the
bathroom. Minimal facilities can create problems in urinary control. Depression is not usually
related to incontinence.
E) An immobilized client may wet the bed if a call light is not within reach; a client with
Alzheimer disease may perceive the urge to void but be unable to interpret its meaning or
respond by seeking a bathroom. A client with impaired vision may not be able to find the
bathroom. Minimal facilities can create problems in urinary control. Depression is not usually
related to incontinence.
Page Ref: 301
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Communication and Documentation
Learning Outcome: 2. Identify risk factors and prevention methods associated with bladder
incontinence and retention.

38
Copyright © 2015 Pearson Education, Inc.
10) The nurse is caring for a client with functional incontinence. The nurse is aware that which
of the following are factors of functional incontinence?
Select all that apply.
A) Fecal impaction
B) Depression
C) Confusion
D) Prostate surgery
E) Impaired mobility
Answer: B, C, E
Explanation: A) Functional incontinence occurs when the ability to respond to the need to
urinate is impaired. Contributing factors may include confusion, depression, or impaired
mobility. Fecal incontinence is a contributing factor to overflow incontinence and prostate
surgery is a contributing factor to stress incontinence.
B) Functional incontinence occurs when the ability to respond to the need to urinate is impaired.
Contributing factors may include confusion, depression, or impaired mobility. Fecal
incontinence is a contributing factor to overflow incontinence and prostate surgery is a
contributing factor to stress incontinence.
C) Functional incontinence occurs when the ability to respond to the need to urinate is impaired.
Contributing factors may include confusion, depression, or impaired mobility. Fecal
incontinence is a contributing factor to overflow incontinence and prostate surgery is a
contributing factor to stress incontinence.
D) Functional incontinence occurs when the ability to respond to the need to urinate is impaired.
Contributing factors may include confusion, depression, or impaired mobility. Fecal
incontinence is a contributing factor to overflow incontinence and prostate surgery is a
contributing factor to stress incontinence.
E) Functional incontinence occurs when the ability to respond to the need to urinate is impaired.
Contributing factors may include confusion, depression, or impaired mobility. Fecal
incontinence is a contributing factor to overflow incontinence and prostate surgery is a
contributing factor to stress incontinence.
Page Ref: 294
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of bladder incontinence and retention.

39
Copyright © 2015 Pearson Education, Inc.
11) The nurse reviewing discharge instructions with a client and his wife would identify the need
for further instruction when the client's wife makes which statement?
A) "While he is taking the antibiotics, it is very important for him to drink a generous amount of
water to prevent damage to his kidneys."
B) "Drinking cranberry juice will decrease the risk for developing urinary tract infections."
C) "We should contact his doctor prior to his taking any over-the-counter medication."
D) "Drinking cranberry juice will increase the risk for developing calcium-based urinary stones."
Answer: D
Explanation: A) Consuming cranberry juice and foods that acidify the urine reduces, not
increases, the risk of repeated urinary tract infections and reduces, not increases, the formation of
calcium-based urinary stones. Antibiotics can damage the kidneys; therefore, it is important to
maintain a generous fluid intake while taking antibiotics. The client should contact the physician
prior to taking any over-the-counter medication due to the risk of urinary retention when taking
over-the-counter medications.
B) Consuming cranberry juice and foods that acidify the urine reduces, not increases, the risk of
repeated urinary tract infections and reduces, not increases, the formation of calcium-based
urinary stones. Antibiotics can damage the kidneys; therefore, it is important to maintain a
generous fluid intake while taking antibiotics. The client should contact the physician prior to
taking any over-the-counter medication due to the risk of urinary retention when taking over-the-
counter medications.
C) Consuming cranberry juice and foods that acidify the urine reduces, not increases, the risk of
repeated urinary tract infections and reduces, not increases, the formation of calcium-based
urinary stones. Antibiotics can damage the kidneys; therefore, it is important to maintain a
generous fluid intake while taking antibiotics. The client should contact the physician prior to
taking any over-the-counter medication due to the risk of urinary retention when taking over-the-
counter medications.
D) Consuming cranberry juice and foods that acidify the urine reduces, not increases, the risk of
repeated urinary tract infections and reduces, not increases, the formation of calcium-based
urinary stones. Antibiotics can damage the kidneys; therefore, it is important to maintain a
generous fluid intake while taking antibiotics. The client should contact the physician prior to
taking any over-the-counter medication due to the risk of urinary retention when taking over-the-
counter medications.
Page Ref: 304
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Evaluation
Learning Outcome: 6. Plan evidence-based care for an individual with bladder incontinence or
retention and his or her family in collaboration with other members of the healthcare team.

40
Copyright © 2015 Pearson Education, Inc.
12) The charge nurse is observing a newly licensed nurse catheterize a 76-year-old male client
admitted with an enlarged prostate. Which action observed would indicate to the charge nurse
the need to intervene?
A) The newly licensed nurse injects 10 mL of 2% lidocaine gel into the client's urethra.
B) The newly licensed nurse inserts a 16 French coudé-tipped catheter.
C) The newly licensed nurse clamps the catheter after draining 500 mL.
D) The newly licensed nurse clamps the catheter after draining 800 mL.
Answer: D
Explanation: A) Using 2% lidocaine gel 10 mL injected into the male urethra reduces
discomfort during catheterization and the risk of catheter-associated infection, and it promotes
pelvic muscle relaxation. A coudé-tipped catheter is passed more easily in the older man with an
enlarged prostate. Some clients experience a vasovagal response, becoming pale, sweaty, and
hypotensive, if the bladder is rapidly drained. Draining urine in 500 mL increments and clamping
the catheter for 5-10 minutes between increments may prevent this response. Draining 800 mL
before clamping might cause a vasovagal response, so the charge nurse would need to intervene.
B) Using 2% lidocaine gel 10 mL injected into the male urethra reduces discomfort during
catheterization and the risk of catheter-associated infection, and it promotes pelvic muscle
relaxation. A coudé-tipped catheter is passed more easily in the older man with an enlarged
prostate. Some clients experience a vasovagal response, becoming pale, sweaty, and hypotensive,
if the bladder is rapidly drained. Draining urine in 500 mL increments and clamping the catheter
for 5-10 minutes between increments may prevent this response. Draining 800 mL before
clamping might cause a vasovagal response, so the charge nurse would need to intervene.
C) Using 2% lidocaine gel 10 mL injected into the male urethra reduces discomfort during
catheterization and the risk of catheter-associated infection, and it promotes pelvic muscle
relaxation. A coudé-tipped catheter is passed more easily in the older man with an enlarged
prostate. Some clients experience a vasovagal response, becoming pale, sweaty, and hypotensive,
if the bladder is rapidly drained. Draining urine in 500 mL increments and clamping the catheter
for 5-10 minutes between increments may prevent this response. Draining 800 mL before
clamping might cause a vasovagal response, so the charge nurse would need to intervene.
D) Using 2% lidocaine gel 10 mL injected into the male urethra reduces discomfort during
catheterization and the risk of catheter-associated infection, and it promotes pelvic muscle
relaxation. A coudé-tipped catheter is passed more easily in the older man with an enlarged
prostate. Some clients experience a vasovagal response, becoming pale, sweaty, and hypotensive,
if the bladder is rapidly drained. Draining urine in 500 mL increments and clamping the catheter
for 5-10 minutes between increments may prevent this response. Draining 800 mL before
clamping might cause a vasovagal response, so the charge nurse would need to intervene.
Page Ref: 300-301
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing Process: Teaching and Learning
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with bladder incontinence and retention.

41
Copyright © 2015 Pearson Education, Inc.
13) The nurse at a health fair is educating clients on risk factors associated with urinary
incontinence. The nurse is aware that which is a non-modifiable risk factor?
A) Age
B) Obesity
C) Smoking
D) Diabetes
Answer: A
Explanation: A) Age is a non-modifiable risk factor and is a primary risk factor for the
development of urinary incontinence; older individuals experience more frequent incontinence
than younger individuals. Obesity, smoking, diabetes, inactivity, pregnancy, and depression are
all modifiable risk factors for urinary incontinence.
B) Age is a non-modifiable risk factor and is a primary risk factor for the development of urinary
incontinence; older individuals experience more frequent incontinence than younger individuals.
Obesity, smoking, diabetes, inactivity, pregnancy, and depression are all modifiable risk factors
for urinary incontinence.
C) Age is a non-modifiable risk factor and is a primary risk factor for the development of urinary
incontinence; older individuals experience more frequent incontinence than younger individuals.
Obesity, smoking, diabetes, inactivity, pregnancy, and depression are all modifiable risk factors
for urinary incontinence.
D) Age is a non-modifiable risk factor and is a primary risk factor for the development of urinary
incontinence; older individuals experience more frequent incontinence than younger individuals.
Obesity, smoking, diabetes, inactivity, pregnancy, and depression are all modifiable risk factors
for urinary incontinence.
Page Ref: 297-298
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Teaching and Learning
Learning Outcome: 2. Identify risk factors and prevention methods associated with bladder
incontinence and retention.

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Exemplar 5.3 Bowel Incontinence, Constipation, and Impaction

1) The nurse is taking care of a client who states that he ignores the urge to defecate when he is
at work. The client states, "I don't like to have a bowel movement anywhere but at home." Which
response by the nurse would explain why this practice should be changed?
A) "This is a common practice, and it will strengthen the reflex later."
B) "You will get the urge later, so you should not worry about it."
C) "If you continue to ignore the urge to defecate, it can lead to problems."
D) "It is better to suppress the urge than to suffer embarrassment at work."
Answer: C
Explanation: A) When the normal defecation reflexes are inhibited, these conditioned reflexes
tend to be progressively weakened. When the urge to defecate is ignored, water continues to be
reabsorbed, making the feces hard and difficult to expel. Ignoring the urge repeatedly will
eventually cause the urge to be lost. Embarrassment, while unwarranted, is preferable to losing
the urge to defecate. Ignoring the urge will not strengthen the reflex later; it will weaken it.
B) When the normal defecation reflexes are inhibited, these conditioned reflexes tend to be
progressively weakened. When the urge to defecate is ignored, water continues to be reabsorbed,
making the feces hard and difficult to expel. Ignoring the urge repeatedly will eventually cause
the urge to be lost. Embarrassment, while unwarranted, is preferable to losing the urge to
defecate. Ignoring the urge will not strengthen the reflex later; it will weaken it.
C) When the normal defecation reflexes are inhibited, these conditioned reflexes tend to be
progressively weakened. When the urge to defecate is ignored, water continues to be reabsorbed,
making the feces hard and difficult to expel. Ignoring the urge repeatedly will eventually cause
the urge to be lost. Embarrassment, while unwarranted, is preferable to losing the urge to
defecate. Ignoring the urge will not strengthen the reflex later; it will weaken it.
D) When the normal defecation reflexes are inhibited, these conditioned reflexes tend to be
progressively weakened. When the urge to defecate is ignored, water continues to be reabsorbed,
making the feces hard and difficult to expel. Ignoring the urge repeatedly will eventually cause
the urge to be lost. Embarrassment, while unwarranted, is preferable to losing the urge to
defecate. Ignoring the urge will not strengthen the reflex later; it will weaken it.
Page Ref: 306
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of bowel incontinence, constipation, and impaction.

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2) A client is being seen in an ambulatory care clinic. The client tells the nurse about
experiencing frequent diarrhea. The nurse inquires about the client's diet. Which statement from
the client would be of greatest concern for the nurse?
A) "I like to eat a bran muffin and applesauce every morning for breakfast."
B) "I like to eat popcorn for an afternoon snack."
C) "I like to eat cottage cheese, peaches, and a turkey sandwich for lunch."
D) "I like to eat baked chicken, yeast rolls, and a small salad for dinner."
Answer: C
Explanation: A) Dairy products can contain lactose, which might be difficult for certain clients
to digest, resulting in diarrhea. The remaining selections are not associated with diarrhea.
B) Dairy products can contain lactose, which might be difficult for certain clients to digest,
resulting in diarrhea. The remaining selections are not associated with diarrhea.
C) Dairy products can contain lactose, which might be difficult for certain clients to digest,
resulting in diarrhea. The remaining selections are not associated with diarrhea.
D) Dairy products can contain lactose, which might be difficult for certain clients to digest,
resulting in diarrhea. The remaining selections are not associated with diarrhea.
Page Ref: 276
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 2. Identify risk factors and prevention methods associated with bowel
incontinence, constipation, and impaction.

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3) The nurse is caring for a client from another culture. The client tells the nurse that he is
constipated. What is the nurse's initial action?
A) Encourage the client to increase fluid intake and activity.
B) Assess the client's intake of fiber and fluids.
C) Determine what the client means by constipation.
D) Obtain an order for a laxative and an enema from the physician.
Answer: C
Explanation: A) The nurse should first carefully evaluate the client's concern and question the
person as to what he considers to be constipation. Determining the client's normal frequency of
bowel movement, consistency of stool, and effort in passing stool is important before deciding to
act. The other suggestions–achieving adequate fluid intake, exercising, including fiber in the diet,
and using a laxative (and possibly an enema)–may be appropriate once the nurse has adequately
assessed the client's concern of constipation.
B) The nurse should first carefully evaluate the client's concern and question the person as to
what he considers to be constipation. Determining the client's normal frequency of bowel
movement, consistency of stool, and effort in passing stool is important before deciding to act.
The other suggestions–achieving adequate fluid intake, exercising, including fiber in the diet,
and using a laxative (and possibly an enema)–may be appropriate once the nurse has adequately
assessed the client's concern of constipation.
C) The nurse should first carefully evaluate the client's concern and question the person as to
what he considers to be constipation. Determining the client's normal frequency of bowel
movement, consistency of stool, and effort in passing stool is important before deciding to act.
The other suggestions–achieving adequate fluid intake, exercising, including fiber in the diet,
and using a laxative (and possibly an enema)–may be appropriate once the nurse has adequately
assessed the client's concern of constipation.
D) The nurse should first carefully evaluate the client's concern and question the person as to
what he considers to be constipation. Determining the client's normal frequency of bowel
movement, consistency of stool, and effort in passing stool is important before deciding to act.
The other suggestions–achieving adequate fluid intake, exercising, including fiber in the diet,
and using a laxative (and possibly an enema)–may be appropriate once the nurse has adequately
assessed the client's concern of constipation.
Page Ref: 307
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with bowel incontinence, constipation, and impaction.

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Copyright © 2015 Pearson Education, Inc.
4) The nurse is planning care for a newly admitted bed-bound elderly client. Which nursing
diagnosis would be most appropriate for a client on bed rest?
A) Risk of Bowel Incontinence
B) Disturbed Body Image
C) Risk of Diarrhea
D) Risk of Constipation
Answer: D
Explanation: A) Lack of activity, like bed rest, is a major contributor to constipation. Lack of
movement slows bowel movements. Lack of sphincter control, not bed rest, contributes to bowel
incontinence. Diarrhea would come from a GI upset triggered by diseases, medication, or diet.
Disturbed Body Image would affect a client who has undergone a bowel diversion.
B) Lack of activity, like bed rest, is a major contributor to constipation. Lack of movement slows
bowel movements. Lack of sphincter control, not bed rest, contributes to bowel incontinence.
Diarrhea would come from a GI upset triggered by diseases, medication, or diet. Disturbed Body
Image would affect a client who has undergone a bowel diversion.
C) Lack of activity, like bed rest, is a major contributor to constipation. Lack of movement slows
bowel movements. Lack of sphincter control, not bed rest, contributes to bowel incontinence.
Diarrhea would come from a GI upset triggered by diseases, medication, or diet. Disturbed Body
Image would affect a client who has undergone a bowel diversion.
D) Lack of activity, like bed rest, is a major contributor to constipation. Lack of movement slows
bowel movements. Lack of sphincter control, not bed rest, contributes to bowel incontinence.
Diarrhea would come from a GI upset triggered by diseases, medication, or diet. Disturbed Body
Image would affect a client who has undergone a bowel diversion.
Page Ref: 315
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for individuals with
bowel incontinence, constipation, or impaction.

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Copyright © 2015 Pearson Education, Inc.
5) The nurse is caring for a client who has been experiencing intermittent diarrhea. The client has
been advised to increase the amount of soluble fiber in the diet. The nurse has instructed the
client and spouse regarding appropriate dietary choices. Which food selection by the client
indicates that teaching has been effective?
Select all that apply.
A) Sunflower seeds
B) Carrot slices
C) Spinach salad
D) Corn muffins
E) Peas
Answer: B, E
Explanation: A) Soluble fibers prolong stomach emptying time. Carrot slices and peas are
sources of soluble fiber. The remaining selections are sources of insoluble fiber.
B) Soluble fibers prolong stomach emptying time. Carrot slices and peas are sources of soluble
fiber. The remaining selections are sources of insoluble fiber.
C) Soluble fibers prolong stomach emptying time. Carrot slices and peas are sources of soluble
fiber. The remaining selections are sources of insoluble fiber.
D) Soluble fibers prolong stomach emptying time. Carrot slices and peas are sources of soluble
fiber. The remaining selections are sources of insoluble fiber.
E) Soluble fibers prolong stomach emptying time. Carrot slices and peas are sources of soluble
fiber. The remaining selections are sources of insoluble fiber.
Page Ref: 310
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for individuals with bowel incontinence,
constipation, and impaction and their families in collaboration with other members of the
healthcare team.

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Copyright © 2015 Pearson Education, Inc.
6) The nurse is admitting a child who has had diarrhea for 1 week. The nurse is writing the plan
of care for the client. What is an appropriate goal for this client?
A) The client will increase the amount of sugar in the diet.
B) The client will defecate regularly by discharge.
C) The client will limit fluid intake for 3 days.
D) The client will regain normal stool consistency by discharge.
Answer: D
Explanation: A) As this client is experiencing diarrhea, the goal will be to regain normal stool
consistency, which means less water will be in the stool, resulting in a more formed consistency.
Defecating regularly once the diarrhea has subsided can be a goal, but it is too soon for this goal;
the problem needs to be corrected first. Since the client is experiencing diarrhea, which can
dehydrate the body and promote electrolyte loss, limiting fluid is not appropriate. Increasing the
amount of sugar in the diet will just add to the diarrhea.
B) As this client is experiencing diarrhea, the goal will be to regain normal stool consistency,
which means less water will be in the stool, resulting in a more formed consistency. Defecating
regularly once the diarrhea has subsided can be a goal, but it is too soon for this goal; the
problem needs to be corrected first. Since the client is experiencing diarrhea, which can
dehydrate the body and promote electrolyte loss, limiting fluid is not appropriate. Increasing the
amount of sugar in the diet will just add to the diarrhea.
C) As this client is experiencing diarrhea, the goal will be to regain normal stool consistency,
which means less water will be in the stool, resulting in a more formed consistency. Defecating
regularly once the diarrhea has subsided can be a goal, but it is too soon for this goal; the
problem needs to be corrected first. Since the client is experiencing diarrhea, which can
dehydrate the body and promote electrolyte loss, limiting fluid is not appropriate. Increasing the
amount of sugar in the diet will just add to the diarrhea.
D) As this client is experiencing diarrhea, the goal will be to regain normal stool consistency,
which means less water will be in the stool, resulting in a more formed consistency. Defecating
regularly once the diarrhea has subsided can be a goal, but it is too soon for this goal; the
problem needs to be corrected first. Since the client is experiencing diarrhea, which can
dehydrate the body and promote electrolyte loss, limiting fluid is not appropriate. Increasing the
amount of sugar in the diet will just add to the diarrhea.
Page Ref: 282
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 7. Evaluate expected outcomes for individuals with bowel incontinence,
constipation, and impaction.

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Copyright © 2015 Pearson Education, Inc.
7) The nurse is preparing to discharge a client with diarrhea. The physician has ordered kaolin to
manage the client's diarrhea. The nurse instructs the client concerning use of the medication.
What client statement indicates the need for further teaching?
A) "If my diarrhea does not get better within 2 days, I will need to call my physician for further
advice."
B) "I will need to take the medication after each loose stool."
C) "I should continue to take this medication daily until my stools are firm and dry."
D) "If I start to have a fever, I need to contact my physician about continuing to take this
medication."
Answer: C
Explanation: A) Continuing to take the medication daily until the stools are firm and dry could
result in constipation. If constipation occurs, the client will have another issue for resolution. The
other statements are correct.
B) Continuing to take the medication daily until the stools are firm and dry could result in
constipation. If constipation occurs, the client will have another issue for resolution. The other
statements are correct.
C) Continuing to take the medication daily until the stools are firm and dry could result in
constipation. If constipation occurs, the client will have another issue for resolution. The other
statements are correct.
D) Continuing to take the medication daily until the stools are firm and dry could result in
constipation. If constipation occurs, the client will have another issue for resolution. The other
statements are correct.
Page Ref: 283
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of individuals with bowel incontinence, constipation, and impaction.

49
Copyright © 2015 Pearson Education, Inc.
8) The home health nurse is visiting a client with a history of constipation. The physician has
order psyllium mucilloid (Metamucil) for the client. The nurse has just completed medication
teaching. Which statement by the client indicates the need for further teaching?
A) "This medication is a lot more natural than other laxatives."
B) "I may be able to stop my Lipitor with this medication."
C) "This medication takes several days to work."
D) "I don't need to drink extra fluids while I take this medication."
Answer: D
Explanation: A) Fluids must be increased when clients use psyllium mucilloid (Metamucil).
Psyllium mucilloid (Metamucil) does take several days to work. Psyllium mucilloid (Metamucil)
does help to reduce cholesterol levels; therefore, the client may be able to stop the Lipitor.
Psyllium mucilloid (Metamucil) is more natural than other laxatives.
B) Fluids must be increased when clients use psyllium mucilloid (Metamucil). Psyllium
mucilloid (Metamucil) does take several days to work. Psyllium mucilloid (Metamucil) does
help to reduce cholesterol levels; therefore, the client may be able to stop the Lipitor. Psyllium
mucilloid (Metamucil) is more natural than other laxatives.
C) Fluids must be increased when clients use psyllium mucilloid (Metamucil). Psyllium
mucilloid (Metamucil) does take several days to work. Psyllium mucilloid (Metamucil) does
help to reduce cholesterol levels; therefore, the client may be able to stop the Lipitor. Psyllium
mucilloid (Metamucil) is more natural than other laxatives.
D) Fluids must be increased when clients use psyllium mucilloid (Metamucil). Psyllium
mucilloid (Metamucil) does take several days to work. Psyllium mucilloid (Metamucil) does
help to reduce cholesterol levels; therefore, the client may be able to stop the Lipitor. Psyllium
mucilloid (Metamucil) is more natural than other laxatives.
Page Ref: 283
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for individuals with bowel incontinence,
constipation, and impaction and their families in collaboration with other members of the
healthcare team.

50
Copyright © 2015 Pearson Education, Inc.
9) You have been providing educational and supportive assistance for Brian, a 4-year-old client
with encopresis. Which statement would indicate parental understanding of appropriate care?
Select all that apply.
A) "We established a limited schedule of activities that has many breaks so that he has the
opportunity to use the toilet regularly."
B) "We brought Brian to a play therapist to deal with adjusting to our new baby."
C) "We didn't change his diet because we were afraid it would stress him out."
D) "We've worked on regular elimination after morning and evening meals."
Answer: A, B, D
Explanation: A) The underlying constipation that leads to encopresis may be caused by the
stress of a full schedule of activities or other environmental changes (e.g., birth of a sibling).
Dietary changes including incorporating high-fiber foods and limiting refined and highly
processed foods and dairy products may be helpful. It takes several months for the bowel to be
retrained to respond to sphincter stimulation.
B) The underlying constipation that leads to encopresis may be caused by the stress of a full
schedule of activities or other environmental changes (e.g., birth of a sibling). Dietary changes
including incorporating high-fiber foods and limiting refined and highly processed foods and
dairy products may be helpful. It takes several months for the bowel to be retrained to respond to
sphincter stimulation.
C) The underlying constipation that leads to encopresis may be caused by the stress of a full
schedule of activities or other environmental changes (e.g., birth of a sibling). Dietary changes
including incorporating high-fiber foods and limiting refined and highly processed foods and
dairy products may be helpful. It takes several months for the bowel to be retrained to respond to
sphincter stimulation.
D) The underlying constipation that leads to encopresis may be caused by the stress of a full
schedule of activities or other environmental changes (e.g., birth of a sibling). Dietary changes
including incorporating high-fiber foods and limiting refined and highly processed foods and
dairy products may be helpful. It takes several months for the bowel to be retrained to respond to
sphincter stimulation.
Page Ref: 314
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for individuals with bowel incontinence,
constipation, and impaction.

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Copyright © 2015 Pearson Education, Inc.
10) The nurse is caring for a client with chronic constipation. The nurse is aware that which may
be causes of constipation?
Select all that apply.
A) Bed rest
B) High-fiber foods
C) Low-fiber foods
D) Chronic laxative use
E) Depression
Answer: A, C, D, E
Explanation: A) Lack of exercise and bed rest may contribute to constipation. Stool softeners
and laxatives may be beneficial for clients experiencing acute constipation but should not be
used for an extended period of time, because they can lead to intestinal problems and worsening
constipation. Emotional disturbances can contribute to constipation, such as depression and
mental confusion. Dietary measures to prevent constipation include eating a diet high in fiber
and limiting low-fiber intake, as well as drinking plenty of fluids.
B) Lack of exercise and bed rest may contribute to constipation. Stool softeners and laxatives
may be beneficial for clients experiencing acute constipation but should not be used for an
extended period of time, because they can lead to intestinal problems and worsening
constipation. Emotional disturbances can contribute to constipation, such as depression and
mental confusion. Dietary measures to prevent constipation include eating a diet high in fiber
and limiting low-fiber intake, as well as drinking plenty of fluids.
C) Lack of exercise and bed rest may contribute to constipation. Stool softeners and laxatives
may be beneficial for clients experiencing acute constipation but should not be used for an
extended period of time, because they can lead to intestinal problems and worsening
constipation. Emotional disturbances can contribute to constipation, such as depression and
mental confusion. Dietary measures to prevent constipation include eating a diet high in fiber
and limiting low-fiber intake, as well as drinking plenty of fluids.
D) Lack of exercise and bed rest may contribute to constipation. Stool softeners and laxatives
may be beneficial for clients experiencing acute constipation but should not be used for an
extended period of time, because they can lead to intestinal problems and worsening
constipation. Emotional disturbances can contribute to constipation, such as depression and
mental confusion. Dietary measures to prevent constipation include eating a diet high in fiber
and limiting low-fiber intake, as well as drinking plenty of fluids.
E) Lack of exercise and bed rest may contribute to constipation. Stool softeners and laxatives
may be beneficial for clients experiencing acute constipation but should not be used for an
extended period of time, because they can lead to intestinal problems and worsening
constipation. Emotional disturbances can contribute to constipation, such as depression and
mental confusion. Dietary measures to prevent constipation include eating a diet high in fiber
and limiting low-fiber intake, as well as drinking plenty of fluids.
Page Ref: 306
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of bowel incontinence, constipation, and impaction.

52
Copyright © 2015 Pearson Education, Inc.
11) The client is experiencing constipation. The physician orders Metamucil, a bulk-forming
laxative. The nurse is aware that which is a nursing consideration when administering this
medication?
A) The client must always take with sufficient water.
B) Can be administered orally or rectally.
C) Used to treat acute constipation
D) May cause tardive dyskinesia.
Answer: A
Explanation: A) It is imperative that the client take Metamucil with a sufficient amount of water
for the medication to be effective. Metamucil is an oral medication, and it is not typically for use
in the treatment of acute constipation, as results from the medication are not immediate.
Prokinetic drugs such as Reglan may cause tardive dyskinesia. Metamucil is not associated with
the cause of tardive dyskinesia.
B) It is imperative that the client take Metamucil with a sufficient amount of water for the
medication to be effective. Metamucil is an oral medication, and it is not typically for use in the
treatment of acute constipation, as results from the medication are not immediate. Prokinetic
drugs such as Reglan may cause tardive dyskinesia. Metamucil is not associated with the cause
of tardive dyskinesia.
C) It is imperative that the client take Metamucil with a sufficient amount of water for the
medication to be effective. Metamucil is an oral medication, and it is not typically for use in the
treatment of acute constipation, as results from the medication are not immediate. Prokinetic
drugs such as Reglan may cause tardive dyskinesia. Metamucil is not associated with the cause
of tardive dyskinesia.
D) It is imperative that the client take Metamucil with a sufficient amount of water for the
medication to be effective. Metamucil is an oral medication, and it is not typically for use in the
treatment of acute constipation, as results from the medication are not immediate. Prokinetic
drugs such as Reglan may cause tardive dyskinesia. Metamucil is not associated with the cause
of tardive dyskinesia.
Page Ref: 309
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of individuals with bowel incontinence, constipation, and impaction.

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Copyright © 2015 Pearson Education, Inc.
12) The nurse is reviewing discharge instructions with the mother of a toddler who was
hospitalized for constipation due to withholding. The nurse would identify the need for further
instruction when the client's mother makes which statement?
A) "I should recognize that when my child walks stiffly on his tiptoes, this could indicate
withholding."
B) "Rocking and crossing the legs could be a sign of withholding."
C) "I need to make sure my child eats a low-fiber diet."
D) "Soiling could be a sign of withholding because of involuntary overflow."
Answer: C
Explanation: A) The most common clinical manifestations of withholding in children are
tightening of the external sphincter and gluteal muscles, squatting, rocking, stiff walking on
tiptoes, crossing legs, sitting with heels against the perineum, stretching of the rectum and lower
colon, stool retention, and soiling by involuntary overflow. Clinical dietary therapies for
withholding include a high-fiber diet and adequate fluid intake. Therefore, the mother's comment
regarding ensuring that a low-fiber diet be provided to the child would indicate the need for
further instruction. The child would be encouraged to eat a diet high in fiber.
B) The most common clinical manifestations of withholding in children are tightening of the
external sphincter and gluteal muscles, squatting, rocking, stiff walking on tiptoes, crossing legs,
sitting with heels against the perineum, stretching of the rectum and lower colon, stool retention,
and soiling by involuntary overflow. Clinical dietary therapies for withholding include a high-
fiber diet and adequate fluid intake. Therefore, the mother's comment regarding ensuring that a
low-fiber diet be provided to the child would indicate the need for further instruction. The child
would be encouraged to eat a diet high in fiber.
C) The most common clinical manifestations of withholding in children are tightening of the
external sphincter and gluteal muscles, squatting, rocking, stiff walking on tiptoes, crossing legs,
sitting with heels against the perineum, stretching of the rectum and lower colon, stool retention,
and soiling by involuntary overflow. Clinical dietary therapies for withholding include a high-
fiber diet and adequate fluid intake. Therefore, the mother's comment regarding ensuring that a
low-fiber diet be provided to the child would indicate the need for further instruction. The child
would be encouraged to eat a diet high in fiber.
D) The most common clinical manifestations of withholding in children are tightening of the
external sphincter and gluteal muscles, squatting, rocking, stiff walking on tiptoes, crossing legs,
sitting with heels against the perineum, stretching of the rectum and lower colon, stool retention,
and soiling by involuntary overflow. Clinical dietary therapies for withholding include a high-
fiber diet and adequate fluid intake. Therefore, the mother's comment regarding ensuring that a
low-fiber diet be provided to the child would indicate the need for further instruction. The child
would be encouraged to eat a diet high in fiber.
Page Ref: 315
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Evaluation
Learning Outcome: 6. Plan evidence-based care for individuals with bowel incontinence,
constipation, and impaction and their families in collaboration with other members of the
healthcare team.

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Copyright © 2015 Pearson Education, Inc.
13) The nurse is preparing to teach a class on constipation prevention. The nurse is aware that
high-fiber foods should be suggested and that which food is high in fiber?
A) Raw fruits
B) Cooked vegetables
C) White bread
D) Cooked fruits
Answer: A
Explanation: A) Foods high in fiber include raw fruits, bran products, and whole grain products.
Low-fiber foods would include cooked fruits, cooked vegetables, and white bread.
B) Foods high in fiber include raw fruits, bran products, and whole grain products. Low-fiber
foods would include cooked fruits, cooked vegetables, and white bread.
C) Foods high in fiber include raw fruits, bran products, and whole grain products. Low-fiber
foods would include cooked fruits, cooked vegetables, and white bread.
D) Foods high in fiber include raw fruits, bran products, and whole grain products. Low-fiber
foods would include cooked fruits, cooked vegetables, and white bread.
Page Ref: 315
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Nursing Process: Teaching and Learning
Learning Outcome: 2. Identify risk factors and prevention methods associated with bowel
incontinence, constipation, and impaction.

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Copyright © 2015 Pearson Education, Inc.
Exemplar 5.4 Urinary Calculi

1) The nurse is triaging a client who presents to the urgent care clinic with symptoms of severe
flank pain with spasms, nausea, vomiting, and oliguria. The client states that the pain was
initially intermittent and radiated from the lower back to the lower quadrants of the abdomen.
What should the nurse do next?
A) Complete the physical assessment.
B) Refer the client to a urologist immediately.
C) Instruct the client to increase fluids.
D) Obtain a urine specimen for culture.
Answer: B
Explanation: A) Hydroureter is a complication that occurs when a renal calculus moves into the
ureter and blocks and dilates the ureter. Symptoms include severe pain and spasms, nausea,
vomiting, and diminished volume of urine. Hydroureter is a medical emergency that can lead to
shock, infection, and subsequent impaired renal function; medical collaboration should be
initiated immediately. All other options, while important to complete, would not be appropriate
in an emergency situation.
B) Hydroureter is a complication that occurs when a renal calculus moves into the ureter and
blocks and dilates the ureter. Symptoms include severe pain and spasms, nausea, vomiting, and
diminished volume of urine. Hydroureter is a medical emergency that can lead to shock,
infection, and subsequent impaired renal function; medical collaboration should be initiated
immediately. All other options, while important to complete, would not be appropriate in an
emergency situation.
C) Hydroureter is a complication that occurs when a renal calculus moves into the ureter and
blocks and dilates the ureter. Symptoms include severe pain and spasms, nausea, vomiting, and
diminished volume of urine. Hydroureter is a medical emergency that can lead to shock,
infection, and subsequent impaired renal function; medical collaboration should be initiated
immediately. All other options, while important to complete, would not be appropriate in an
emergency situation.
D) Hydroureter is a complication that occurs when a renal calculus moves into the ureter and
blocks and dilates the ureter. Symptoms include severe pain and spasms, nausea, vomiting, and
diminished volume of urine. Hydroureter is a medical emergency that can lead to shock,
infection, and subsequent impaired renal function; medical collaboration should be initiated
immediately. All other options, while important to complete, would not be appropriate in an
emergency situation.
Page Ref: 319
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of urinary calculi.

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2) A graduate nurse has joined the staff in the care of renal clients. The graduate asks the
preceptor what puts a client at risk urinary calculi. The nurse identifies which client as having the
greatest risk for urinary stones?
A) A 35-year-old female with quadriplegia from an auto accident
B) A 65-year-old male with a recent history of myocardial infarction
C) A 50-year-old male with type II diabetes mellitus
D) A 25-year-old female with several episodes of urinary infection
Answer: A
Explanation: A) The 35-year-old female with quadriplegia from an auto accident experiences
prolonged immobility, which will increase calcium loss from bones and therefore increase the
chance of calcium stones precipitating in the urinary system. A 65-year-old male with a recent
history of myocardial infarction, 50-year-old male with type II diabetes mellitus, and 25-year-old
female with several episodes of urinary infection do not have as great a risk because they do not
remain immobile for long periods of time.
B) The 35-year-old female with quadriplegia from an auto accident experiences prolonged
immobility, which will increase calcium loss from bones and therefore increase the chance of
calcium stones precipitating in the urinary system. A 65-year-old male with a recent history of
myocardial infarction, 50-year-old male with type II diabetes mellitus, and 25-year-old female
with several episodes of urinary infection do not have as great a risk because they do not remain
immobile for long periods of time.
C) The 35-year-old female with quadriplegia from an auto accident experiences prolonged
immobility, which will increase calcium loss from bones and therefore increase the chance of
calcium stones precipitating in the urinary system. A 65-year-old male with a recent history of
myocardial infarction, 50-year-old male with type II diabetes mellitus, and 25-year-old female
with several episodes of urinary infection do not have as great a risk because they do not remain
immobile for long periods of time.
D) The 35-year-old female with quadriplegia from an auto accident experiences prolonged
immobility, which will increase calcium loss from bones and therefore increase the chance of
calcium stones precipitating in the urinary system. A 65-year-old male with a recent history of
myocardial infarction, 50-year-old male with type II diabetes mellitus, and 25-year-old female
with several episodes of urinary infection do not have as great a risk because they do not remain
immobile for long periods of time.
Page Ref: 320
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 2. Identify risk factors and prevention methods associated with urinary
calculi.

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3) The nurse educator is speaking with a group of students about renal disorders. The educator
knows that which statement is true about renal stones?
A) The elderly are particularly at risk for urolithiasis.
B) Young- or middle-adulthood men are at an increased risk for stones.
C) Women are affected more than men.
D) Frequency is greater in the northern United States.
Answer: B
Explanation: A) Men who are in young to middle adulthood are affected 2-3 times more than
women of that age. The frequency of the occurrence of renal stones in the United States is
greatest in the southern and midwestern states.
B) Men who are in young to middle adulthood are affected 2-3 times more than women of that
age. The frequency of the occurrence of renal stones in the United States is greatest in the
southern and midwestern states.
C) Men who are in young to middle adulthood are affected 2-3 times more than women of that
age. The frequency of the occurrence of renal stones in the United States is greatest in the
southern and midwestern states.
D) Men who are in young to middle adulthood are affected 2-3 times more than women of that
age. The frequency of the occurrence of renal stones in the United States is greatest in the
southern and midwestern states.
Page Ref: 319-320
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across life span for individuals with urinary calculi.

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4) A female client is admitted to the Emergency Department and diagnosed with urinary calculi.
The client reports that she has had symptoms for 1 week. The nurse is planning care for the
client. Which nursing diagnosis is appropriate for this client?
A) Risk for Constipation
B) Risk for Disuse Syndrome
C) Imbalanced Nutrition
D) Activity Intolerance
Answer: C
Explanation: A) The client with urinary calculi, or kidney stones, of lengthy duration is at risk
for imbalanced nutrition from the resulting nausea. Activity intolerance, risk for constipation,
and risk for disuse syndrome are not as appropriate because the symptoms of urinary calculi do
not lead to these diagnoses.
B) The client with urinary calculi, or kidney stones, of lengthy duration is at risk for imbalanced
nutrition from the resulting nausea. Activity intolerance, risk for constipation, and risk for disuse
syndrome are not as appropriate because the symptoms of urinary calculi do not lead to these
diagnoses.
C) The client with urinary calculi, or kidney stones, of lengthy duration is at risk for imbalanced
nutrition from the resulting nausea. Activity intolerance, risk for constipation, and risk for disuse
syndrome are not as appropriate because the symptoms of urinary calculi do not lead to these
diagnoses.
D) The client with urinary calculi, or kidney stones, of lengthy duration is at risk for imbalanced
nutrition from the resulting nausea. Activity intolerance, risk for constipation, and risk for disuse
syndrome are not as appropriate because the symptoms of urinary calculi do not lead to these
diagnoses.
Page Ref: 329
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
urinary calculi.

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5) The nurse is caring for a client with a history of kidney stones. The stones have been analyzed
and are all composed of calcium phosphate. The nurse teaches this client to reduce intake of
which foods?
A) Chicken, beef, and ham products
B) Organ meats, sardines, and seafood
C) Tomatoes, fruits, and nuts
D) Flour, milk, and ice cream
Answer: D
Explanation: A) Flour, milk, and milk products such as ice cream have high calcium levels and,
therefore, are recommended to be reduced to decrease the risk of further episodes of calcium-
containing calculi. Organ meats, sardines, seafood, tomatoes, fruits, nuts, chicken, beef, and ham
products are not high in calcium and do not need to be restricted for this client.
B) Flour, milk, and milk products such as ice cream have high calcium levels and, therefore, are
recommended to be reduced to decrease the risk of further episodes of calcium-containing
calculi. Organ meats, sardines, seafood, tomatoes, fruits, nuts, chicken, beef, and ham products
are not high in calcium and do not need to be restricted for this client.
C) Flour, milk, and milk products such as ice cream have high calcium levels and, therefore, are
recommended to be reduced to decrease the risk of further episodes of calcium-containing
calculi. Organ meats, sardines, seafood, tomatoes, fruits, nuts, chicken, beef, and ham products
are not high in calcium and do not need to be restricted for this client.
D) Flour, milk, and milk products such as ice cream have high calcium levels and, therefore, are
recommended to be reduced to decrease the risk of further episodes of calcium-containing
calculi. Organ meats, sardines, seafood, tomatoes, fruits, nuts, chicken, beef, and ham products
are not high in calcium and do not need to be restricted for this client.
Page Ref: 330
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with urinary calculi and his or
her family in collaboration with other members of the healthcare team.

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6) A client with urinary calculi has been admitted to the hospital. The nurse is planning care for
this client. Which goal is appropriate for this client?
A) The client will lose 25 pounds in 3 months.
B) The client will ambulate three times a day.
C) The client will request pain medication at the onset of pain.
D) The client will shower independently.
Answer: C
Explanation: A) Intense pain is the hallmark of urinary calculi, or kidney stones, that are passing
through the urinary system. The nurse teaches the client to request pain medication at the onset
of pain in order to provide faster relief. The client with urinary calculi is able to ambulate and
shower independently. Dietary changes will need to be made to prevent further formation of
stones, but weight loss is not necessarily a goal with this disease process.
B) Intense pain is the hallmark of urinary calculi, or kidney stones, that are passing through the
urinary system. The nurse teaches the client to request pain medication at the onset of pain in
order to provide faster relief. The client with urinary calculi is able to ambulate and shower
independently. Dietary changes will need to be made to prevent further formation of stones, but
weight loss is not necessarily a goal with this disease process.
C) Intense pain is the hallmark of urinary calculi, or kidney stones, that are passing through the
urinary system. The nurse teaches the client to request pain medication at the onset of pain in
order to provide faster relief. The client with urinary calculi is able to ambulate and shower
independently. Dietary changes will need to be made to prevent further formation of stones, but
weight loss is not necessarily a goal with this disease process.
D) Intense pain is the hallmark of urinary calculi, or kidney stones, that are passing through the
urinary system. The nurse teaches the client to request pain medication at the onset of pain in
order to provide faster relief. The client with urinary calculi is able to ambulate and shower
independently. Dietary changes will need to be made to prevent further formation of stones, but
weight loss is not necessarily a goal with this disease process.
Page Ref: 329
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 7. Evaluate expected outcomes for an individual with urinary calculi.

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7) The nurse is preparing the client for treatment of renal calculi that have failed to respond to
medication therapy. What is the preferred treatment?
A) Lithotripsy
B) Surgery on the kidney to remove the stones
C) Diet control
D) Increasing fluids
Answer: A
Explanation: A) When medication fails to dissolve stones, the preferred method of treatment is
lithotripsy, which is using sound waves to crush the stones so they can be passed out of the
urinary system. Depending on the location of the stones, surgery may be the next step in the
treatment process. Diet and fluids are used to prevent further stone formation.
B) When medication fails to dissolve stones, the preferred method of treatment is lithotripsy,
which is using sound waves to crush the stones so they can be passed out of the urinary system.
Depending on the location of the stones, surgery may be the next step in the treatment process.
Diet and fluids are used to prevent further stone formation.
C) When medication fails to dissolve stones, the preferred method of treatment is lithotripsy,
which is using sound waves to crush the stones so they can be passed out of the urinary system.
Depending on the location of the stones, surgery may be the next step in the treatment process.
Diet and fluids are used to prevent further stone formation.
D) When medication fails to dissolve stones, the preferred method of treatment is lithotripsy,
which is using sound waves to crush the stones so they can be passed out of the urinary system.
Depending on the location of the stones, surgery may be the next step in the treatment process.
Diet and fluids are used to prevent further stone formation.
Page Ref: 322
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with urinary calculi.

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Copyright © 2015 Pearson Education, Inc.
8) The nurse is preparing to discharge a client who was admitted with a kidney stone. The client
underwent a lithotripsy. What should the nurse teach the client to prevent further complications
of urinary calculi after discharge?
A) "You will need to increase your oral fluid intake to 1L/day."
B) "It will be important that you not drive while taking pain medications."
C) "It will be important to maintain a diet high in purines."
D) "You will need to monitor for the signs and symptoms of a urinary tract infection (UTI)."
Answer: D
Explanation: A) The client with stones may develop a UTI when formed stones obstruct urinary
flow. These symptoms should be reported as early as possible to the primary care provider. By
discharge, the stones should have passed and there would be no need for pain medication. Fluid
intake per day should be 2.5-3.0 L. Foods high in purines, such as organ meats, are to be
avoided.
B) The client with stones may develop a UTI when formed stones obstruct urinary flow. These
symptoms should be reported as early as possible to the primary care provider. By discharge, the
stones should have passed and there would be no need for pain medication. Fluid intake per day
should be 2.5-3.0 L. Foods high in purines, such as organ meats, are to be avoided.
C) The client with stones may develop a UTI when formed stones obstruct urinary flow. These
symptoms should be reported as early as possible to the primary care provider. By discharge, the
stones should have passed and there would be no need for pain medication. Fluid intake per day
should be 2.5-3.0 L. Foods high in purines, such as organ meats, are to be avoided.
D) The client with stones may develop a UTI when formed stones obstruct urinary flow. These
symptoms should be reported as early as possible to the primary care provider. By discharge, the
stones should have passed and there would be no need for pain medication. Fluid intake per day
should be 2.5-3.0 L. Foods high in purines, such as organ meats, are to be avoided.
Page Ref: 330
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with urinary calculi and his or
her family in collaboration with other members of the healthcare team.

63
Copyright © 2015 Pearson Education, Inc.
9) A client is complaining of dull flank pain. List the order of the steps the nurse should take in
conducting a physical assessment.
1. Instruct the client.
2. Assess the general appearance.
3. Position the client.
4. Inspect the abdomen for color, contour, symmetry, and distention.
Answer: 1, 3, 2, 4
Explanation: A quick survey of the client enables the nurse to identify any immediate problem
as well as the client's ability to participate in the assessment. Begin the examination with the
client in a supine position with the abdomen exposed from the nipple line to the pubis. Assess
general appearance and inspect the client's skin for color, hydration status, scales, masses,
indentations, or scars.
Page Ref: 324
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of urinary calculi.

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10) The nurse is updating the plan of care for a client with renal calculi. The nurse is aware that
which are expected outcomes of a client with renal calculi?
Select all that apply.
A) The client rates pain at a 2 on a scale of 1-10 and states that a 2 is acceptable.
B) The client is able to comfortably perform ADLs.
C) The client demonstrates a fluid intake of 800-1,000mL/day.
D) The client remains free of signs and symptoms of infection.
E) The client chooses the appropriate diet to prevent the reoccurrence of renal calculi.
Answer: A, B, D, E
Explanation: A) While straining of the client's urine may indicate that the stone has passed, it is
important to assess the client for possible complications. Client outcomes should include the
client's rating pain at 3 or less on a 0-10 scale and being comfortable enough to perform own
ADLs, the client demonstrating an adequate fluid intake of 2-3 liters a day, the client's choosing
the appropriate diet to prevent the reoccurrence of renal calculi, and the client's remaining free of
signs and symptoms of infection.
B) While straining of the client's urine may indicate that the stone has passed, it is important to
assess the client for possible complications. Client outcomes should include the client's rating
pain at 3 or less on a 0-10 scale and being comfortable enough to perform own ADLs, the client
demonstrating an adequate fluid intake of 2-3 liters a day, the client's choosing the appropriate
diet to prevent the reoccurrence of renal calculi, and the client's remaining free of signs and
symptoms of infection.
C) While straining of the client's urine may indicate that the stone has passed, it is important to
assess the client for possible complications. Client outcomes should include the client's rating
pain at 3 or less on a 0-10 scale and being comfortable enough to perform own ADLs, the client
demonstrating an adequate fluid intake of 2-3 liters a day, the client's choosing the appropriate
diet to prevent the reoccurrence of renal calculi, and the client's remaining free of signs and
symptoms of infection.
D) While straining of the client's urine may indicate that the stone has passed, it is important to
assess the client for possible complications. Client outcomes should include the client's rating
pain at 3 or less on a 0-10 scale and being comfortable enough to perform own ADLs, the client
demonstrating an adequate fluid intake of 2-3 liters a day, the client's choosing the appropriate
diet to prevent the reoccurrence of renal calculi, and the client's remaining free of signs and
symptoms of infection.
E) While straining of the client's urine may indicate that the stone has passed, it is important to
assess the client for possible complications. Client outcomes should include the client's rating
pain at 3 or less on a 0-10 scale and being comfortable enough to perform own ADLs, the client
demonstrating an adequate fluid intake of 2-3 liters a day, the client's choosing the appropriate
diet to prevent the reoccurrence of renal calculi, and the client's remaining free of signs and
symptoms of infection.
Page Ref: 331
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Planning
Learning Outcome: 7. Evaluate expected outcomes for an individual with urinary calculi.

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Copyright © 2015 Pearson Education, Inc.
11) A client admitted to the hospital with a diagnosis of gout has also been diagnosed with uric
acid renal calculi. Which diet should the nurse anticipate may be ordered by the physician?
A) Low-purine diet
B) Low-sodium diet
C) A diet high in calcium
D) A diet low in calcium
Answer: A
Explanation: A) A low-purine diet is appropriate in the management of a client with uric acid
renal calculi. A low-sodium diet is useful in the management of a client with cystine renal
calculi, and a diet limiting foods high in calcium is useful when managing a client with calcium
phosphate renal calculi.
B) A low-purine diet is appropriate in the management of a client with uric acid renal calculi. A
low-sodium diet is useful in the management of a client with cystine renal calculi, and a diet
limiting foods high in calcium is useful when managing a client with calcium phosphate renal
calculi.
C) A low-purine diet is appropriate in the management of a client with uric acid renal calculi. A
low-sodium diet is useful in the management of a client with cystine renal calculi, and a diet
limiting foods high in calcium is useful when managing a client with calcium phosphate renal
calculi.
D) A low-purine diet is appropriate in the management of a client with uric acid renal calculi. A
low-sodium diet is useful in the management of a client with cystine renal calculi, and a diet
limiting foods high in calcium is useful when managing a client with calcium phosphate renal
calculi.
Page Ref: 323
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with urinary calculi.

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Copyright © 2015 Pearson Education, Inc.
12) A client admitted to the hospital with a diagnosis of inflammatory bowel disease has also
been diagnosed with calcium phosphate renal calculi. Which medication should the nurse
anticipate may be ordered by the physician to prevent further formation of stones?
A) Potassium citrate
B) Indomethacin
C) Morphine sulfate
D) Hydrochlorothiazide
Answer: D
Explanation: A) Hydrochlorothiazide is a thiazide diuretic used to prevent the formation of
calcium stones. Potassium citrate alkalinizes urine (raises the pH) and is often prescribed to
prevent stones that tend to form in acidic urine (uric acid, cystine, and some forms of calcium
stones). Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) that is used to treat pain
and discomfort and may reduce the amount of narcotic analgesia required for acute renal colic.
Morphine sulfate is a narcotic analgesic used to relieve pain.
B) Hydrochlorothiazide is a thiazide diuretic used to prevent the formation of calcium stones.
Potassium citrate alkalinizes urine (raises the pH) and is often prescribed to prevent stones that
tend to form in acidic urine (uric acid, cystine, and some forms of calcium stones). Indomethacin
is a nonsteroidal anti-inflammatory drug (NSAID) that is used to treat pain and discomfort and
may reduce the amount of narcotic analgesia required for acute renal colic. Morphine sulfate is a
narcotic analgesic used to relieve pain.
C) Hydrochlorothiazide is a thiazide diuretic used to prevent the formation of calcium stones.
Potassium citrate alkalinizes urine (raises the pH) and is often prescribed to prevent stones that
tend to form in acidic urine (uric acid, cystine, and some forms of calcium stones). Indomethacin
is a nonsteroidal anti-inflammatory drug (NSAID) that is used to treat pain and discomfort and
may reduce the amount of narcotic analgesia required for acute renal colic. Morphine sulfate is a
narcotic analgesic used to relieve pain.
D) Hydrochlorothiazide is a thiazide diuretic used to prevent the formation of calcium stones.
Potassium citrate alkalinizes urine (raises the pH) and is often prescribed to prevent stones that
tend to form in acidic urine (uric acid, cystine, and some forms of calcium stones). Indomethacin
is a nonsteroidal anti-inflammatory drug (NSAID) that is used to treat pain and discomfort and
may reduce the amount of narcotic analgesia required for acute renal colic. Morphine sulfate is a
narcotic analgesic used to relieve pain.
Page Ref: 323
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with urinary calculi and his or
her family in collaboration with other members of the healthcare team.

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Copyright © 2015 Pearson Education, Inc.
13) The nurse on the medical unit is admitting a 96-year-old client whose primary symptoms
include fatigue, pruritus, and pain in the right flank area. Which assessment technique should not
be used while assessing this client?
A) Palpation over the costovertebral angles and flanks
B) Blunt percussion over the costovertebral angles and flanks
C) Palpation of the lower pole of both kidneys
D) Capturing of both kidneys
Answer: B
Explanation: A) Blunt percussion in a frail older individual is contraindicated. Instead, palpation
of the costovertebral angles and flanks can be used to reveal any pain or tenderness. All other
assessments are appropriate.
B) Blunt percussion in a frail older individual is contraindicated. Instead, palpation of the
costovertebral angles and flanks can be used to reveal any pain or tenderness. All other
assessments are appropriate.
C) Blunt percussion in a frail older individual is contraindicated. Instead, palpation of the
costovertebral angles and flanks can be used to reveal any pain or tenderness. All other
assessments are appropriate.
D) Blunt percussion in a frail older individual is contraindicated. Instead, palpation of the
costovertebral angles and flanks can be used to reveal any pain or tenderness. All other
assessments are appropriate.
Page Ref: 323
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing Process: Assessment
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with urinary calculi.

68
Copyright © 2015 Pearson Education, Inc.