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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A) A mobility assessment evaluates the client's ability to move and perform activities of daily living (ADLs). The nurse should collect data on the client's ability to sit, stand, walk, transfer, and perform self-care tasks.
B) The condition of the client's skin is also relevant because impaired mobility can increase the risk of pressure ulcers.
C) Health literacy level is not directly related to mobility assessment.
D) Mobility assessment includes evaluating the client's ability to perform activities of daily living (ADLs), such as transferring, walking, and self-care tasks.
E) Daily calcium intake is important for bone health but is not directly related to a mobility assessment.
Correct Answer is ["A","B","E"]
Explanation
A) Providing under-bed lighting at night can help clients see better and avoid tripping over objects or cords.
B) This prevents the bed from moving unintentionally, reducing the risk of falls when clients are getting in or out of bed.
C) Keeping the bed at a low position actually helps prevent falls as it reduces the distance a patient can fall.
D) Socks can increase the risk of slipping, so they should be avoided or non-slip socks should be used.
E) Placing breaks on the clients’ wheelchairs can prevent them from rolling away or tipping over when transferring or sitting.
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