A patient requests the nurse's help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient's inability to void?
The patient is lonely and calling then nurse in under false pretenses is a way to get attention.
The patient does not recognize the physiological signals that indicate a need to void.
The patient is not drinking enough fluids to produce adequate urine output.
The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void.
The Correct Answer is D
A. The patient is lonely and calling the nurse under false pretenses. This is an inappropriate assumption. The patient may be experiencing urinary hesitancy due to anxiety, not seeking attention.
B. The patient does not recognize the physiological signals that indicate a need to void. The patient recognized the need to void but is having difficulty due to psychological factors (e.g., anxiety, privacy concerns).
C. The patient is not drinking enough fluids to produce adequate urine output. The patient felt the urge to void, meaning they do have urine in the bladder. The issue is likely related to difficulty initiating urination rather than fluid intake.
D. The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void. Paruresis ("shy bladder syndrome") can make it difficult to void in the presence of others due to anxiety or embarrassment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Take the medication with a full glass of water." Docusate is a stool softener that works best when taken with plenty of fluids.
B. "Expect abdominal pain with this medication." Docusate should not cause abdominal pain; if it does, it should be discontinued.
C. "Take this medication on an empty stomach." Docusate can be taken with or without food.
D. "Do not take this medication before bedtime." It is often recommended before bedtime to work overnight.
Correct Answer is B
Explanation
A. Continuous output from the stoma. Ileostomies typically have continuous liquid output, which is expected.
B. Presence of blood in the stool: Blood in the stool can indicate stomal irritation, ulceration, or bleeding from the intestines, which requires immediate medical attention.
C. Malodorous stool. While foul-smelling stool can suggest an issue (e.g., infection), it is not necessarily an emergency.
D. Liquid consistency with hard stool particles. Ileostomy output is expected to be liquid, and occasional solid particles may occur if certain foods are not fully digested.
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