After surgery, a post-operative patient has not urinated for 8 hours.
Where should the nurse check for bladder distention?
Palpate between the symphysis pubis and the umbilicus
Palpate over the costovertebral region of the flank
Palpate in the left lower quadrant of the abdomen
Palpate between ribs 11 and 12 and the umbilicus
The Correct Answer is A
Anatomy: The bladder is a hollow, muscular organ located in the lower abdomen, just behind the pubic bone. It stores urine until it is emptied through urination. The area between the symphysis pubis (the joint where the two pubic bones meet) and the umbilicus (belly button) is directly over the bladder, making it the most appropriate place to palpate for bladder distention.
Signs of bladder distention: When the bladder is distended, it can be felt as a firm, round mass in the lower abdomen. The patient may also experience discomfort, pressure, or an urge to urinate.
Nursing assessment: Palpation is a key nursing assessment skill used to evaluate the size, shape, and position of organs within the abdomen. In this case, palpation helps the nurse to determine if the bladder is distended and to assess the severity of the distention.
Clinical significance: Bladder distention can occur for a variety of reasons, including:
Postoperative urinary retention due to anesthesia or pain medications
Urinary tract obstruction (e.g., from a kidney stone or enlarged prostate)
Neurological conditions that affect bladder function (e.g., spinal cord injury, multiple sclerosis)
Dehydration
Certain medications (e.g., diuretics, anticholinergics)
Prompt intervention: Bladder distention can lead to complications such as urinary tract infections, kidney damage, and discomfort. It's important for the nurse to identify and address bladder distention promptly to prevent these complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Reduced kidney ability to concentrate urine is a common physiological change associated with normal aging. This is due to several factors, including:
Decreased glomerular filtration rate (GFR): The kidneys filter waste products from the blood. As we age, the number of functioning nephrons (filtering units) in the kidneys decreases, leading to a decline in GFR. This means that the kidneys are less able to filter waste products and concentrate urine.
Decreased renal blood flow: Blood flow to the kidneys also decreases with age. This further reduces the kidneys' ability to filter waste products and concentrate urine.
Decreased tubular function: The tubules in the kidneys are responsible for reabsorbing water and electrolytes from the urine. As we age, the function of the tubules also declines, leading to a decrease in the ability to concentrate urine.
As a result of these changes, older adults often produce more urine, even at night. This can lead to nocturia, which is the need to wake up to urinate two or more times per night.
Choice B rationale:
Lower fluid intake during daytime hours can also contribute to nocturia, but it is not a direct physiological change associated with normal aging. Older adults may drink less fluids during the day for a variety of reasons, such as decreased thirst sensation, fear of incontinence, or limited access to fluids. However, even if they maintain adequate fluid intake during the day, they may still experience nocturia due to the reduced ability of their kidneys to concentrate urine.
Choice C rationale:
Enhanced bladder contractility leading to urinary stasis is not a typical physiological change associated with normal aging. In fact, bladder contractility often decreases with age, which can lead to difficulty emptying the bladder completely. This can contribute to urinary frequency and urgency, but it is not typically a cause of nocturia.
Choice D rationale:
Increased bladder muscle tone leading to frequent urination is also not a typical physiological change associated with normal aging. Bladder muscle tone may decrease with age, which can lead to difficulty emptying the bladder completely. However, it is not typically a cause of nocturia.
Correct Answer is C
Explanation
Choice A rationale:
The physical dimension addresses the body's biological and physiological systems, such as organs, tissues, and cells. It does not directly relate to seeking support from others.
While the mother's actions may indirectly impact her child's physical health by reducing stress and potentially improving asthma management, the primary focus of her behavior is social connection and support, not physical interventions.
Choice B rationale:
The intellectual and spiritual dimension encompasses a person's thoughts, beliefs, values, and sense of purpose. While seeking support can involve sharing thoughts and beliefs, the mother's primary motivation is likely to connect with others who share similar experiences, rather than to explore intellectual or spiritual aspects of asthma.
Choice C rationale:
The socio-cultural dimension involves the social and cultural factors that influence a person's health and well-being. This includes:
Relationships with family, friends, and community
Cultural beliefs and practices
Social norms and expectations
Access to resources and support systems
The mother's desire to connect with other parents of children with asthma clearly demonstrates the influence of social relationships and shared experiences on her coping and support-seeking behavior.
This aligns with the concept of social support, which has been shown to have significant benefits for both physical and mental health.
Choice D rationale:
The environmental dimension refers to the physical and social surroundings that affect a person's health. While the environment can play a role in asthma management (e.g., exposure to allergens), it is not the primary focus of the mother's actions in seeking support from other parents.
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