A nurse is planning care for a patient who is immobile and is experiencing urinary retention.
The nurse should plan to monitor the patient for which of the following?
Neurogenic bladder
Urinary tract infection
Bladder outlet obstruction
Genitourinary System Effects
Genitourinary System Effects
The Correct Answer is B
Choice A rationale
Neurogenic bladder is a condition where a person lacks bladder control due to a brain, spinal cord or nerve condition. This is not the most fitting answer because the scenario does not provide information about any neurological conditions.
Choice B rationale
Urinary retention can lead to urinary tract infections. The retained urine provides a breeding ground for bacteria, which can lead to infection.
Choice C rationale
Bladder outlet obstruction is a condition where the bladder is not able to empty properly. While urinary retention could be a symptom of this condition, the scenario does not provide enough information to suggest this diagnosis.
Choice D rationale
Genitourinary System Effects is a broad term that refers to any effects on the genital and urinary systems. This is not the most fitting answer because it is less specific than Choice B2.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Ascending muscle weakness is a classic symptom of Guillain-Barre syndrome. It often starts in the feet and legs before spreading to the upper body and arms.
Choice B rationale
Difficulty with urination is not a typical symptom of Guillain-Barre syndrome.
Choice C rationale
Ptosis (drooping of the upper eyelid) and diplopia (double vision) are not common symptoms of Guillain-Barre syndrome.
Choice D rationale
Ear distortion and pain are not associated with Guillain-Barre syndrome.
Correct Answer is A
Explanation
Choice A rationale
The first physiological response that occurs during the General Adaptation Syndrome (GAS) is
the alarm reaction stage. This stage is the body’s initial response to stress, where the sympathetic nervous system is activated by the sudden release of hormones.
Choice B rationale
The body remaining alert while blood pressure and heart rate return to pre-stress levels is part of the resistance stage of GAS, not the first physiological response.
Choice C rationale
Prolonged exposure to stress resulting in illness is associated with the exhaustion stage of GAS, which is the final stage, not the first physiological response.
Choice D rationale
An increase in hormones causing an increase in blood pressure and heart rate is part of the alarm reaction stage, but it is not the first physiological response. The first response is the perception of a stressor that stimulates the central nervous system.
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