A nurse is assisting with the plan of care for a client who is immobile and is experiencing urinary retention. The nurse should plan to monitor the client for which of the following?

Bladder outlet obstruction

Protein in the urine

Neurogenic bladder

Urinary tract infection

Answer and Explanation

The Correct Answer is D

A)   Urine retention is a common symptom of bladder outlet obstruction but in this case assessing the patient for a urinary tract infection is the priority.

B)   While proteinuria can indicate kidney dysfunction, it's not directly related to urinary retention.
C)   This refers to bladder dysfunction due to neurological causes and may not be directly related to urinary retention in an immobile client.
D)   Immobility can increase the risk of urinary tract infections Urinary retention can lead to urinary tract infection (UTI) due to bacterial growth in the stagnant urine. The nurse should monitor the client for signs and symptoms of UTI, such as fever, chills, dysuria, hematuria, and foul-smelling urine.

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Correct Answer is C

Explanation

A) The lens tends to become less flexible with age, affecting accommodation.

B) The lens may become thicker with age, contributing to presbyopia.

C) Age-related changes such as decreased pupil size and changes in visual acuity can lead to reduced depth perception.
D) Aging can lead to decreased muscle tone, including in the eye muscles, which may affect accommodation and focus.

A. Place the chair on the client's left side. B. Raise the height of the client's bed. C. Lock the wheels on the client's bed. D. Place the chair at a 90° angle to the bed.

Correct Answer is C

Explanation

A) The chair should be placed on the client's stronger (right) side to facilitate a safer and more controlled transfer. The client can use their stronger side to assist in the movement.

B) The bed should be at a comfortable height, ideally level with the chair, to allow a smooth transfer. Raising the bed too high can make it difficult for the client to place their feet firmly on the ground, reducing stability.
C) Locking the wheels on the bed ensures stability and prevents movement while assisting the client with the transfer. This is a crucial safety measure to reduce the risk of falls or injuries during the transfer process.
D) The chair should be positioned at a 45° angle to the bed to allow for a more natural pivot and smoother transfer. A 90° angle can make the movement more difficult and awkward for the client.

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A nurse is assisting with the plan of care for a client who is immobile and is experiencing urinary retention. The nurse should plan to monitor the client for which of the following?

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