A patient calls the office to tell you that his or her urine has changed orange in color. The best response of the nurse is which of the following?

Did you recently drink a lot of cranberry juice?

Did you recently start taking any new medication?

Please make an appointment with the office right away.

Have you noticed any blood on the tissue when you wipe yourself?

Answer and Explanation

The Correct Answer is B

Choice A reason: Cranberry juice typically causes pink or reddish urine, not orange. Orange urine is more commonly linked to medications, dehydration, or liver issues. Asking about cranberry juice is less relevant, as it does not directly address the most likely causes of orange discoloration.

Choice B reason: Medications like rifampin, phenazopyridine, or certain vitamins (e.g., B vitamins) can cause orange urine due to their pigments or metabolites excreted renally. Inquiring about new medications is a targeted approach to identify a common, benign cause before escalating to invasive diagnostics.

Choice C reason: Immediately scheduling an appointment assumes a serious condition without exploring benign causes like medications or dehydration. This response may cause unnecessary alarm and overlooks a systematic assessment, which could resolve the issue through history-taking alone.

Choice D reason: Blood in urine (hematuria) typically causes red or brown discoloration, not orange. Asking about blood is less relevant to orange urine and may confuse the patient, as it does not align with the reported symptom’s likely etiology.

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Correct Answer is B

Explanation

Choice A reason: Pulling fluid into the bowel describes osmotic laxatives (e.g., lactulose), which increase water content to soften stool and stimulate peristalsis. Bulk-forming agents work by absorbing water to increase stool volume, not by osmotically drawing fluid.

Choice B reason: Bulk-forming agents (e.g., psyllium) absorb water in the intestine, swelling to form a bulky, soft stool that stimulates peristalsis. Taken with adequate water, they promote regular bowel movements, making this the accurate description.

Choice C reason: Softening the fecal mass describes stool softeners (e.g., docusate), which reduce stool surface tension to allow water penetration. Bulk-forming agents primarily increase stool volume, not just soften it, distinguishing their mechanism.

Choice D reason: Causing local irritation describes stimulant laxatives (e.g., bisacodyl), which irritate the mucosa to enhance motility and reduce water absorption. Bulk-forming agents work mechanically by adding bulk, not through chemical irritation.

A. Take the client to the bathroom every 2 hr. B. Request a prescription for an indwelling urinary catheter C. Remind the client to tell the nurse when he has to urinate. D. Use adult diapers to prevent frequent clothing changes.

Correct Answer is A

Explanation

Choice A reason: Scheduled toileting every 2 hours establishes a routine, compensating for dementia-related cognitive deficits in recognizing bladder cues. This promotes continence, reduces accidents, and maintains dignity, making it the most effective behavioral intervention.

Choice B reason: Indwelling catheters increase risks of urinary tract infections, skin breakdown, and discomfort, especially in dementia patients unable to communicate issues. They are a last resort, not appropriate for managing incontinence without medical necessity.

Choice C reason: Reminding a dementia patient to report urination needs is ineffective, as cognitive impairment limits their ability to recognize or communicate bladder signals. This approach does not address the underlying issue of incontinence.

Choice D reason: Adult diapers manage accidents but do not promote continence or address the behavior. They may reduce dignity and increase skin breakdown risk, making scheduled toileting a more proactive and dignified intervention.

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A patient calls the office to tell you that his or her urine has changed orange in color. The best response of the nurse is which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

There are a variety of medications that are commonly used to promote healthy bowel elimination. Which best describes a bulk-forming agent?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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