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When caring for older adult clients at a long-term care facility, which of the following assessments should the nurse prioritize when evaluating for the risk and presence of urinary retention? (Select all that apply.)

Observing for changes in urinary patterns, such as a sudden decrease in urinary output or frequent, small amounts of voiding.

Assessing for reports of urinary hesitancy, dribbling of urine, straining, or a sensation of incomplete bladder emptying during urination.

Encouraging the client to drink large amounts of fluid in a short period to stimulate bladder emptying.

Applying pressure over the lower abdomen to force urine out of the bladder.

Evaluating for palpable bladder distention after voiding to assess incomplete bladder emptying.

Answer and Explanation

Correct Answer : A,B,E

A. Observing for changes in urinary patterns, such as a sudden decrease in urinary output or frequent, small amounts of voiding. This can indicate urinary retention, as frequent, small voids may suggest incomplete emptying of the bladder.

B. Assessing for reports of urinary hesitancy, dribbling of urine, straining, or a sensation of incomplete bladder emptying during urination. These symptoms are common in urinary retention, indicating that the client is having difficulty fully emptying the bladder.

C. Encouraging the client to drink large amounts of fluid in a short period to stimulate bladder emptying: This is incorrect, as overhydration can worsen urinary retention, especially in clients with an impaired ability to empty their bladder.

D. Applying pressure over the lower abdomen to force urine out of the bladder: This is incorrect and can cause harm, as it may increase the risk of bladder injury.

E. Evaluating for palpable bladder distention after voiding to assess incomplete bladder emptying.
A distended bladder after voiding suggests incomplete emptying and potential urinary retention.

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Correct Answer is C

Explanation

A. Crohn's disease causes continuous inflammation of the mucosa and sub-mucosa of the colon and rectal linings: This description is more applicable to ulcerative colitis, which involves continuous inflammation and primarily affects the colon and rectum, not Crohn's disease, which can affect any part of the GI tract.

B. Crohn's disease is characterized by a transmural granulomatous inflammation that can affect any part of the gastrointestinal tract: While this is an accurate medical description of Crohn’s disease, it uses technical language that may be difficult for a patient to understand.

C. Crohn's disease has the appearance of a patchwork quilt with some areas that are clear and some with sores. This description provides a clear and visual explanation of the nature of Crohn’s disease, which typically affects the gastrointestinal tract in a "skip lesion" pattern, where some areas are inflamed (sores), and others appear normal (clear areas).

D. Crohn's disease looks like what would appear to be a second-degree burn in the colon and rectum areas only: This description is inaccurate for Crohn’s disease, as it implies the disease is limited to the colon and rectum, which is not the case. Crohn’s can affect any part of the gastrointestinal tract from the mouth to the anus.

A. Administer intravenous antibiotics and observe the patient for 24 hours. B. Provide the patient with oral pain medications and discharge them with a follow-up appointment. C. Recommend a liquid diet and bed rest to reduce inflammation. D. Prepare the patient for an appendectomy.

Correct Answer is D

Explanation

A. Administer intravenous antibiotics and observe the patient for 24 hours: IV antibiotics may be given preoperatively, but observation without surgery is not the standard treatment for confirmed appendicitis due to the risk of rupture.

B. Provide the patient with oral pain medications and discharge them with a follow-up appointment: Oral pain medications are not appropriate as the patient needs surgical intervention. Discharging the patient without surgery could result in life-threatening complications.

C. Recommend a liquid diet and bed rest to reduce inflammation: A liquid diet and bed rest will not address the underlying issue of appendicitis, which requires surgical removal of the inflamed appendix.

D. Prepare the patient for an appendectomy. The standard treatment for acute appendicitis is an appendectomy. Delaying surgery can lead to complications such as perforation, peritonitis, or abscess formation. This is the most appropriate intervention.

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When caring for older adult clients at a long-term care facility, which of the following assessments should the nurse prioritize when evaluating for the risk and presence of urinary retention? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing education to a client who has recently been diagnosed with Crohn's disease. Which of the following explanations by the nurse best simplifies and explains the disorder in non-medical terms?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

A nurse is assessing an older adult client who has a urinary tract infection (UTI). Which of the following findings should the nurse identify as unique for this age group?

A patient with Crohn's disease is being discharged from the hospital. The nurse is providing dietary teaching to the patient. Which of the following statements by the patient indicates a correct understanding of the dietary recommendations?

A patient with a history of ulcerative colitis presents to the clinic with complaints of fatigue, dizziness, and pallor. Upon further assessment, you suspect chronic blood loss. Which potential complication is most likely contributing to these symptoms?

A nurse is reinforcing teaching about renal transplant with a newly licensed nurse. Which of the following clients should the nurse identify as having a contraindication for this procedure?

A patient with suspected appendicitis is being prepared for surgery. Which of the following preoperative interventions should the nurse prioritize?

A nurse is reinforcing teaching to a client who has been newly diagnosed with hepatitis C. The client asks how they could have contracted the virus. Which of the following nurse responses best explains how the client may have become infected with hepatitis C?

A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority?

A female patient recently underwent a partial gastrectomy and is now presenting with symptoms of weakness, dizziness, and sweating, particularly after meals. Based on these symptoms, what is the most likely diagnosis?