A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?

Remind the client to practice pelvic floor (Kegel) exercises regularly.

Provide a bedside commode for immediate use in the client's room

Explain the need to limit intake of oral fluids to reduce client discomfort.

Teach the client techniques for performing intermittent catheterization.

Answer and Explanation

The Correct Answer is D

A. Remind the client to practice pelvic floor (Kegel) exercises regularly.
Pelvic floor exercises, such as Kegel exercises, are typically recommended for conditions involving weakened pelvic floor muscles. However, in the context of urinary retention related to sensorimotor deficits in multiple sclerosis, the issue is more neurological in nature. Therefore, pelvic floor exercises may not address the underlying problem effectively.

B. Provide a bedside commode for immediate use in the client's room.
While a bedside commode may be beneficial for individuals with mobility issues, it doesn't directly address the problem of urinary retention. It focuses on providing a convenient means for the client to void when needed, but it doesn't address the inability to empty the bladder spontaneously.

C. Explain the need to limit intake of oral fluids to reduce client discomfort.
Limiting oral fluids is not an appropriate intervention for urinary retention. In fact, it could lead to dehydration, which is not a recommended approach. The focus should be on addressing the difficulty in voiding through appropriate techniques.

D. Teach the client techniques for performing intermittent catheterization.
This is the correct choice. Intermittent catheterization is a direct and effective method to manage urinary retention in clients with sensorimotor deficits. Teaching the client how to perform intermittent catheterization empowers them to maintain regular bladder emptying and prevent complications associated with urinary retention.

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Correct Answer is C

Explanation

A. Facial puffiness and periorbital edema:
These are common signs of hypothyroidism but may not require immediate action unless accompanied by severe symptoms.

B. Cold and dry skin:
Cold and dry skin is a characteristic feature of hypothyroidism, but a further decline in the level of consciousness is a more urgent issue.

C. Further decline in the level of consciousness.
A decline in the level of consciousness is a critical sign that requires immediate attention, as it may indicate worsening hypothyroidism, myxedema coma, or other serious complications. Myxedema coma is a life-threatening condition associated with severe hypothyroidism, and it requires prompt medical intervention.

D. Hematocrit of 30% (0.30):
While anemia is a potential complication of hypothyroidism, a hematocrit of 30% alone may not be the most immediate concern compared to a decline in the level of consciousness.

A. Jogs more frequently than usual daily routine. B. Eats a vegetarian diet with cheese 2 to 3 times a day. C. Experiences additional stress since adopting a child. D. Drinks several bottles of carbonated water daily

Correct Answer is D

Explanation

A. Jogs more frequently than usual daily routine:
Exercise, including jogging, is generally not associated with an increased risk of renal calculi. In fact, regular physical activity can have health benefits.

B. Eats a vegetarian diet with cheese 2 to 3 times a day:
A vegetarian diet alone is not necessarily a risk factor for renal calculi. However, the inclusion of high-oxalate foods, such as certain types of cheese, may contribute to the formation of kidney stones.

C. Experiences additional stress since adopting a child:
Stress is not a direct risk factor for renal calculi. However, certain dietary and lifestyle factors play a more significant role in stone formation.

D. Drinks several bottles of carbonated water daily:
This is the correct answer. Consuming large amounts of carbonated water, especially if it is high in phosphoric acid, can contribute to the formation of kidney stones. Carbonated beverages may increase the excretion of calcium in the urine, potentially leading to stone formation.

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A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has a history of hypothyroidism was initially admitted with lethargy and confusion Which additional finding warrants the most immediate action by the nurse?

Correct Answer is C

Explanation

The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi?

Correct Answer is D

Explanation

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