The nurse reviews data from a new client's kidney function test. Which of the following standards of transplant nursing practice is the nurse primarily performing?

Choice A reason: Multiple sclerosis can affect the nerves that control the bladder and sphincter muscles, leading to urinary retention.

Choice B reason: Streptococcal infection is not typically associated with urinary retention unless it specifically affects the urinary tract, which is not common.

Choice C reason: Constipation can cause urinary retention by exerting pressure on the bladder or urethra, obstructing the flow of urine.

Choice D reason: Parkinson's disease can lead to urinary retention due to the impairment of nerve signals that

control the bladder.

Choice E reason: Pelvic organ prolapse can obstruct the urethra, leading to difficulty in emptying the bladder and resulting in urinary retention.

The correct answer is Choice A

Choice A rationale: Headache and restlessness can be signs of a seizure or neurological disturbance, which phenytoin is used to treat. Phenytoin is an anticonvulsant medication that helps control seizures by stabilizing neuronal membranes and reducing excitability.

Choice B rationale: Decreased blood pressure and rapid pulse are not indications for phenytoin administration. These symptoms may suggest hypotension or cardiovascular issues, which require different interventions such as fluid resuscitation or vasopressors.

Choice C rationale: Muscle cramps and chest heaviness are not treated with phenytoin. These symptoms could indicate electrolyte imbalances or cardiac issues, which need specific treatments like electrolyte replacement or cardiac monitoring.

Choice D rationale: Pain and tingling at the access site are not indications for phenytoin administration. These symptoms may suggest local irritation or infection at the dialysis access site, requiring appropriate wound care or antibiotics.