A nurse is caring for older adult clients at a long-term care facility. Which of the following assessments should the nurse consider when monitoring clients for urinary retention? (Select all that apply.)
Dribbling of urine
Color of the urine
Voiding patern
Proteinuria
Bladder distension
Correct Answer : A,C,E
Choice A reason: Dribbling of urine can indicate urinary retention, as it may suggest that the bladder is not emptying
completely during voiding.
Choice B reason: While the color of the urine can provide information about hydration status and other health issues, it is not a direct indicator of urinary retention.
Choice C reason: The voiding patern is an important assessment for urinary retention. Infrequent voiding or small amounts despite a full bladder can be signs of this condition.
Choice D reason: Proteinuria is not typically used as an assessment for urinary retention. It can indicate kidney damage or disease but does not directly relate to the bladder's ability to empty.
Choice E reason: Bladder distension can be observed and palpated in cases of urinary retention, as the bladder may become enlarged due to the accumulation of urine.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Acute tubular necrosis (ATN) is a condition where there is damage to the renal tubular cells, which can lead to a decrease in GFR. This is because the tubular cells are responsible for reabsorbing substances from the filtrate back into the blood. When these cells are injured, they cannot function properly, leading to a buildup of waste products and a decrease in GFR.
Choice B reason: While obstruction can lead to a decrease in GFR, it is not the primary cause in the context of acute tubular necrosis. Obstruction typically occurs in postrenal causes of acute kidney injury.
Choice C reason: In?ammatory cells do invade damaged kidneys, but this is more characteristic of conditions such as acute interstitial nephritis rather than ATN. In ATN, the primary issue is the injury to the tubular cells themselves.
Choice D reason: A reduction of blood flow to the kidneys, or prerenal azotemia, can indeed lead to a decrease in GFR. However, in the context of ATN, the primary issue is not the blood flow but the damage to the renal tubules.
Correct Answer is D
Explanation
Choice A reason: Hypernatremia, which is an abnormally high level of sodium in the blood, is not typically associated with prerenal AKI. Prerenal AKI is often related to hypovolemia, which can lead to hyponatremia rather than hypernatremia.
Choice B reason: Hypophosphatemia, or low levels of phosphate in the blood, is not a common finding in prerenal AKI. Phosphate levels are more often affected in intrinsic renal diseases or refeeding syndrome.
Choice C reason: Hypercalcemia, or high levels of calcium in the blood, is not commonly seen in prerenal AKI. It is more frequently associated with malignancies or hyperparathyroidism.
Choice D reason: Hyperkalemia, which is an elevated level of potassium in the blood, is a common electrolyte imbalance in prerenal AKI. This occurs due to decreased renal perfusion and the kidney's reduced ability to excrete potassium.
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