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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Stoma is purple. A purple, dusky, or black stoma indicates poor blood circulation, possibly due to ischemia or necrosis. This is a surgical emergency requiring immediate attention.

B. Stoma is moist. Normal finding, indicating adequate perfusion.

C. Stoma is flush with the skin. Possible but not necessarily abnormal. However, a retracted stoma (sunken below skin level) could lead to leakage and skin irritation.

D. Stoma is protruding from the abdomen. Normal in the early postoperative period. A slight protrusion (bud-like shape) is expected. However, significant prolapse (excessive protrusion) may need evaluation.

Correct Answer is ["740"]

Explanation

4 oz juice → 120 mL
6 oz tea → 180 mL
100 mL ice chips → 50 mL (Ice chips are counted as half their volume when melted)
IV bolus → 150 mL
8 oz broth → 240 mL

Total intake:

120+180+50+150+240=740mL120 + 180 + 50 + 150 + 240=740mL

Correct answer: 740 mL

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately?

Correct Answer is A

Explanation

A nurse is completing an 8-hr 1&0 record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

Correct Answer is ["740"]

Explanation

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