The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority?

Pressure points

Breath sounds

Pulse points

Bowel sounds

Answer and Explanation

The Correct Answer is A

A. Pressure points are critical to assess when evaluating skin integrity, particularly in patients who are immobile or bedridden, as these areas are at high risk for pressure ulcers.

B. Breath sounds are important but are not the priority in assessing skin integrity.

C. Pulse points assess circulation, but they are not directly related to skin integrity.

D. Bowel sounds are relevant for digestive assessments, not for skin integrity.

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Correct Answer is C

Explanation

A. Blood in the urine (hematuria) is not typically associated with urinary retention but can indicate other conditions such as infection or trauma.

B. Cloudy urine may indicate infection but is not a direct sign of urinary retention.

C. Leakage of urine, or overflow incontinence, occurs when the bladder becomes overly full due to retention and releases small amounts of urine involuntarily.

D. Dark-colored urine typically indicates dehydration, which is not a specific sign of urinary retention.

A. Caffeinated beverages B. Dairy products C. Red meat D. Fresh vegetables

Correct Answer is A

Explanation

A. Caffeinated beverages such as coffee, tea, and soda are known bladder irritants and can exacerbate urinary incontinence by increasing bladder contractions.

B. Dairy products are not commonly associated with bladder irritation.

C. Red meat does not irritate the bladder.

D. Fresh vegetables are generally not linked to bladder irritation.

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The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has urinary retention. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is teaching a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation. The nurse should include that which of the following foods and beverages is a bladder irritant?

Correct Answer is A

Explanation

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A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

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Which of the following is a common symptom of a urinary tract infection?

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