When assessing the bladder, the nurse finds that they cannot palpate or percuss the bladder.
This means the bladder is.
Infected.
Distended.
Empty.
Incontinent.
The Correct Answer is C
Choice A rationale
An infected bladder, known as cystitis, typically presents with symptoms such as dysuria, frequency, and urgency rather than a change in physical palpability unless complications like an abscess occur. Laboratory findings such as pyuria, where white blood cell counts exceed 5 per high power field, or a positive nitrite test would indicate infection. The inability to palpate the organ does not correlate with the presence of pathogens within the mucosal lining or the inflammatory response associated with infection.
Choice B rationale
A distended bladder occurs when it contains a significant volume of urine, typically exceeding 200 to 300 mL, making it palpable above the symphysis pubis as a firm, rounded organ. Percussion of a distended bladder would produce a dull sound rather than tympany due to the presence of fluid. Since the nurse cannot find the bladder through these physical assessment techniques, distension is ruled out as the bladder would be easily detectable if it were full of urine.
Choice C rationale
The urinary bladder is a hollow muscular organ located deep within the pelvic cavity behind the symphysis pubis. When it is empty or contains a very small volume of urine, usually less than 50 to 100 mL, it remains below the pelvic brim and is not accessible to manual palpation or percussion. Therefore, the absence of physical findings during a focused abdominal or pelvic assessment is a normal clinical indication that the bladder has been recently emptied or is not holding fluid.
Choice D rationale
Incontinence is the involuntary loss of urine and is a functional or neurological issue rather than an anatomical state that prevents palpation. A patient who is incontinent might have a bladder that is empty because urine is constantly leaking, or they could have an overactive bladder. However, the term incontinence describes the condition of the urinary sphincters and neurological control, while the inability to palpate the bladder specifically refers to the lack of volume within the organ itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Sodium is the primary cation found in the extracellular fluid and plays a critical role in maintaining osmotic pressure and fluid volume. The normal serum sodium range is 135 to 145 mEq/L. Because water follows sodium, it is the most significant factor in determining the distribution of water between the intracellular and extracellular compartments. It is essential for nerve impulse transmission and muscle contraction, and its concentration is tightly regulated by the kidneys and hormones like aldosterone.
Choice B rationale
Potassium is the most abundant cation in the intracellular fluid, not the extracellular fluid. The normal serum range for potassium is 3.5 to 5.0 mEq/L, which is much lower than the sodium concentration in the blood. While its extracellular concentration is small, it is vital for maintaining the resting membrane potential of cells, particularly in cardiac and skeletal muscle. Small shifts in extracellular potassium can have profound effects on heart rhythm, but it remains predominantly an intracellular electrolyte.
Choice C rationale
Calcium is a vital electrolyte for bone health, blood coagulation, and neuromuscular signaling, but it is not the most abundant in the extracellular fluid. The normal total serum calcium range is approximately 8.5 to 10.5 mg/dL. Most of the body's calcium is stored in the skeletal system rather than circulating in the plasma or interstitial fluid. While its presence in the extracellular fluid is crucial for physiological functions, its molar concentration is significantly lower than that of sodium.
Choice D rationale
Magnesium is the second most abundant intracellular cation after potassium and is involved in hundreds of enzymatic reactions, including protein synthesis and DNA repair. The normal serum magnesium range is 1.3 to 2.1 mEq/L. Although it is present in the extracellular fluid and is necessary for cardiovascular and neuromuscular health, its concentration is relatively low compared to sodium. It does not exert the same level of osmotic pull or represent the majority of the extracellular solute load.
Correct Answer is C
Explanation
Choice A rationale
Orthostatic hypotension is primarily associated with cardiovascular issues, fluid volume deficit, or the side effects of antihypertensive medications, rather than direct nephrotoxicity. While severe kidney failure can eventually lead to fluid imbalances that affect blood pressure, it is not the immediate or primary anticipated outcome of a nephrotoxic drug. The student should focus more on the direct physiological impact of the toxin on the renal parenchyma and the subsequent changes in filtration.
Choice B rationale
Nephrotoxic medications typically lead to a decrease in urinary output, known as oliguria, rather than an increase. Damage to the renal tubules or glomeruli impairs the kidney's ability to filter blood and produce urine efficiently. An increase in output would be more indicative of a diuretic effect or a different phase of renal injury. Therefore, the nurse would be more concerned about a drop in output below the minimum expected level of 30 mL/hour.
Choice C rationale
Nephrotoxicity refers to the poisonous effect of certain substances on kidney function, necessitating close monitoring of renal markers. The nurse should anticipate assessing laboratory values such as Serum Creatinine, which normally ranges from 0.6 to 1.2 mg/dL, and Blood Urea Nitrogen, which normally ranges from 10 to 20 mg/dL. These assessments are vital to detect early signs of drug-induced kidney injury and to prevent progression to acute renal failure or permanent damage.
Choice D rationale
Urinary incontinence involves the involuntary loss of urine and is usually related to neuromuscular dysfunction, pelvic floor weakness, or cognitive impairment rather than nephrotoxicity. Nephrotoxicity damages the structural integrity of the kidney itself, affecting filtration and electrolyte balance. While a client with kidney damage might experience changes in the composition or volume of urine, the loss of bladder control is not a standard physiological expectation of medication-induced renal toxicity.
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