What condition occurs when a client's bladder is no longer controlled by the brain because of injury or disease, and they void by reflex only?
Urinary retention.
Micturition.
Autonomic bladder.
Urinary tract infection.
The Correct Answer is C
Choice A rationale
Urinary retention is the inability to completely empty the bladder, often caused by an obstruction, such as an enlarged prostate, or weak bladder muscles. It differs from reflex voiding because the urine remains trapped in the bladder rather than being expelled. While it involves a loss of normal function, it is not defined by the specific reflex action seen when the brain loses its inhibitory control over the micturition center due to a spinal cord injury.
Choice B rationale
Micturition is simply the physiological term for the act of urinating or voiding. It is a complex process involving both autonomic and somatic nervous system components in a healthy individual. In a normal state, the brain provides voluntary control over the external urethral sphincter to delay voiding until appropriate. Because this term refers to the standard process of urination rather than a pathological state of reflex-only voiding, it does not describe the specific condition resulting from injury.
Choice C rationale
Autonomic bladder occurs when the central nervous system is unable to transmit signals between the brain and the urinary system, typically due to spinal cord trauma or disease. In this state, the reflex arc in the sacral region of the spinal cord remains intact, allowing the bladder to empty automatically once it reaches a certain level of fullness. The person loses the ability to perceive the need to void or to voluntarily inhibit the contraction, resulting in reflex-only voiding.
Choice D rationale
A urinary tract infection is an inflammatory response to pathogenic microorganisms, usually bacteria, within the urinary system. Symptoms typically include dysuria, frequency, urgency, and cloudy urine, with normal lab values for white blood cells in urine being less than 5 per high power field. While an infection can irritate the bladder and cause frequency, it does not fundamentally change the neurological control mechanism of the bladder into a reflex-based system as seen in neurologic disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Swelling and coolness at the insertion site are classic indicators of infiltration, which occurs when intravenous fluid enters the surrounding subcutaneous tissue instead of the vein. Infiltration can lead to tissue damage or necrosis depending on the infusate. Normal skin temperature should be maintained at the site. Because the fluid is no longer entering the vascular system, the nurse must immediately stop the infusion and restart the access at a different proximal location to ensure safety.
Choice B rationale
The presence of yellow drainage, or purulence, at the insertion site is a significant sign of localized infection or exit site involvement. This indicates that pathogens have potentially bypassed the skin barrier, posing a risk for systemic bacteremia or sepsis. Standard nursing practice requires the immediate removal of the catheter to prevent further microbial proliferation. The site should be treated, and any subsequent intravenous access must be established at a new, uncontaminated site to protect the client.
Choice C rationale
Tenderness and redness along the path of the vein are hallmark signs of phlebitis, which is inflammation of the inner layer of the vein. This can be caused by chemical irritation, mechanical trauma from the catheter, or bacterial presence. Phlebitis is graded on a scale, but any visible redness and pain necessitate stopping the therapy at that site. Failure to do so can lead to thrombus formation or permanent venous scarring, compromising future vascular access options.
Choice D rationale
When an intravenous fluid stop flowing due to arm position, it is often a mechanical issue related to the catheter tip pressing against a vein wall or a valve. This is considered a positional IV rather than a site failure requiring removal. Adjusting the arm or using an arm board typically resolves the flow rate without needing a new puncture. This finding does not inherently indicate infiltration, infection, or phlebitis, so the access site remains viable for use.
Choice E rationale
Pain without any visible or palpable abnormalities like swelling, redness, or warmth may indicate minor nerve irritation or simple discomfort from the tape or dressing. While the nurse should monitor the site closely, isolated pain does not meet the diagnostic criteria for mandatory site rotation or therapy cessation. The nurse should first assess for external causes of discomfort. If no signs of complication develop, the current access can be maintained while continuing to monitor the client.
Correct Answer is C
Explanation
Choice A rationale
Placing an instrument into the deepest part of the wound bed is the standard procedure for measuring the overall depth of the wound from the surface to the base. While this is a critical component of wound assessment, it does not specifically identify tunneling. Tunneling is a narrow passageway extending in any direction from the edge of the wound, which requires targeted probing specifically beneath the margins rather than just the center base.
Choice B rationale
Measuring along the edge of the wound margin is typically associated with determining the length or width of the wound. Using a ruler or probe in this manner helps track the surface area and healing progress of the wound edges. However, this action stays on the visible perimeter and does not involve entering the hidden tracts that characterize tunneling. Therefore, it is insufficient for assessing the depth or presence of tunnels within the tissue.
Choice C rationale
Tunneling occurs when a narrow opening or tract extends from the wound into the surrounding tissue, often hidden beneath the wound margins. To assess this, the nurse must gently insert a sterile probe or swab under the lip of the wound into the obscured space until resistance is felt. This allows for the measurement of the specific depth and direction of the tunnel, which is vital for proper packing and preventing premature surface closure.
Choice D rationale
Assessing the periwound skin surface involves looking for signs of maceration, erythema, or infection in the tissue surrounding the actual wound. While the health of the periwound skin is essential for overall wound management, it is a surface-level observation. Placing an instrument on top of this area provides no information regarding the internal structures or hidden tracts of the wound. This action is unrelated to the measurement of tunneling depth.
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