A client has undergone a transurethral resection of the prostate (TURP) for benign prostatic hypertrophy (BPH). He is currently being treated with continuous bladder irrigation (CBI) and is complaining of an increase in the severity of bladder spasms. Which intervention should the nurse perform first?
Perform a bladder scan.
Stop the irrigation and note findings in the chart.
Administer an oral analgesic.
Ensure that the catheter is draining properly.
The Correct Answer is D
Choice A Reason
Performing a bladder scan can help determine the volume of urine in the bladder and assess for urinary retention, which could contribute to bladder spasms. However, this is not typically the first intervention. The priority is to ensure that the catheter is patent and draining correctly, as blockages can cause immediate discomfort and increased spasms
Choice B Reason
Stopping the irrigation could be considered if there is a concern that the CBI is contributing to the spasms. However, this would not be the first action taken. It is essential first to assess the catheter's patency and the flow of the irrigation to rule out any obstruction or kinking causing the spasms.
Choice C Reason
Administering an oral analgesic may help alleviate the discomfort caused by bladder spasms, but it does not address the underlying cause. Pain relief is important, but the initial step should be to check for and resolve any mechanical issues with the catheter system that could be causing the spasms.
Choice D Reason
Ensuring that the catheter is draining properly is the first and most crucial intervention. If the catheter is blocked or kinked, it can cause bladder distention and increased spasms. Checking the catheter's patency and the flow of irrigation can quickly resolve the issue and provide relief to the patient. If the catheter is found to be obstructed, resolving the blockage can decrease the severity of the spasms and improve the patient's comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason
A client with paranoid personality disorder is typically not described as superficially charming. This description is more often associated with other personality disorders, such as antisocial personality disorder, where individuals may use charm to manipulate others for personal gain.
Choice B Reason
Being friendly and open is generally not characteristic of paranoid personality disorder. Individuals with this disorder are often wary of others and may be perceived as cold or distant due to their mistrust.
Choice C Reason
While intensity and impulsivity can be seen in various personality disorders, they are not the defining features of paranoid personality disorder. These traits are more commonly associated with borderline personality disorder.
Choice D Reason
Guarded and suspicious are hallmark descriptors for someone with paranoid personality disorder. Individuals with this condition are often very distrustful of others, suspecting that others have ulterior motives or are out to harm them. They may be preoccupied with doubts about the loyalty or trustworthiness of friends or associates.
Correct Answer is ["B","C","D"]
Explanation
Choice A Reason:
The process of being approved for bariatric surgery is not relatively simple. It involves a comprehensive evaluation that includes medical tests, psychological assessment, and dietary counseling. The process can take several months to ensure that the patient is a suitable candidate for surgery.
Choice B Reason:
Behavioral therapy has been shown to be effective for clients seeking to lose weight. It involves strategies such as self-monitoring, developing problem-solving skills, and establishing a support network, which can lead to significant and sustainable weight loss.
Choice C Reason:
Obesity is known to increase the risk of morbidity and mortality. Excess body weight is associated with a higher risk of developing chronic diseases such as type 2 diabetes, cardiovascular diseases, and certain cancers.
Choice D Reason:
Diet and exercise are indeed critical components of a successful weight loss program. A combination of a calorie-restricted diet and regular physical activity is the most effective way to achieve and maintain weight loss.
Choice E Reason:
While weight loss drugs can be an adjunct to diet and exercise for weight loss, they are not universally safe and effective. They can have side effects and are not suitable for everyone. Their use should be evaluated on a case-by-case basis, and they are typically prescribed when lifestyle modifications have not been sufficient.
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