A nurse is educating a group of nursing students about brain herniation.
Which of the following interventions should the nurse include as a potential treatment for brain herniation?

Choice A rationale

Urinary retention refers to the inability to empty the bladder completely. While it can cause discomfort and bloating, it does not typically result in dark amber, cloudy urine with an unpleasant odor.

Choice B rationale

Urinary incontinence is the loss of bladder control, leading to the involuntary leakage of urine. It does not cause the urine to become dark amber, cloudy, or have an unpleasant odor.

Choice C rationale

A urinary tract infection (UTI) is an infection in any part of the urinary system — kidneys, bladder, urethra. Most UTIs are caused by bacteria, but they can also be caused by viruses or fungi. Symptoms of a UTI often include cloudy, dark, or strong-smelling urine.

Choice D rationale

Urinary frequency refers to needing to urinate more often than usual. It can be a symptom of many different issues, including a UTI, but on its own, it does not cause the urine to become dark amber, cloudy, or have an unpleasant odor.

Choice A rationale

Positioning the head of the patient’s bed flat is not typically recommended after a laryngectomy. Instead, the head of the bed is often elevated to help reduce swelling and improve breathing.

Choice B rationale

Providing the patient with humidified air can help keep the airway moist and reduce discomfort, making it a common practice after a laryngectomy.

Choice C rationale

While keeping the surgical site clean is important, cleaning the patient’s sutures every 8 hours is not a standard recommendation and may vary based on the surgeon’s instructions.

Choice D rationale

Suctioning the patient’s mouth on the side of the surgery is not typically recommended as it could potentially disrupt the surgical site.