A nurse is collecting data on a client who has urinary retention. Which of the following findings should the nurse expect?

The correct answer is b. Decreased deep tendon reflexes.

Choice A: Wheezing

Reason: Wheezing is typically associated with respiratory conditions such as asthma, chronic obstructive pulmonary disease (COPD), or allergic reactions. It is not a common manifestation of hyperkalemia. Hyperkalemia primarily affects the muscular and cardiovascular systems rather than the respiratory system.

Choice B: Decreased deep tendon reflexes

Reason: Hyperkalemia can cause neuromuscular symptoms, including muscle weakness and decreased deep tendon reflexes. High potassium levels interfere with the normal function of muscle cells and nerves, leading to these symptoms. This is a direct result of the altered action potentials in neurons caused by elevated potassium levels.

Choice C: Hypoactive bowel sounds

Reason: Hypoactive bowel sounds are generally associated with conditions that cause decreased gastrointestinal motility, such as ileus or bowel obstruction. While hyperkalemia can affect muscle function, it is more likely to cause hyperactive bowel sounds due to increased gastrointestinal motility rather than hypoactive sounds.

Choice D: Cerebral edema

Reason: Cerebral edema is swelling of the brain and is not a typical manifestation of hyperkalemia. It is more commonly associated with conditions such as traumatic brain injury, stroke, or severe infections. Hyperkalemia primarily affects the heart and muscles.

Choice A reason: You should not expect your stoma to be a purple color. A purple stoma indicates ischemia or necrosis, which are serious complications that require immediate medical attention. A healthy stoma should be pink or red and moist.

Choice B reason: Your colostomy will produce formed stool, depending on the location of the colostomy. A sigmoid colostomy is located in the lower part of the large intestine, where most of the water is absorbed from the stool. Therefore, the stool from a sigmoid colostomy will be more solid and regular than from other types of colostomies.

Choice C reason: The end of the stoma will not be painful after this procedure. The stoma is made from the lining of the intestine, which does not have nerve endings that sense pain. However, the skin around the stoma may be sore or irritated from the surgery or the appliance.

Choice D reason: You will have a stoma in your left lower abdomen. A sigmoid colostomy is created by bringing the end of the sigmoid colon, which is the last segment of the large intestine, through an opening in the left lower quadrant of the abdomen. The stoma is then attached to the skin and covered with an appliance that collects the stool.