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When caring for older adult clients at a long-term care facility, which of the following assessments should the nurse prioritize when evaluating for the risk and presence of urinary retention? (Select all that apply.)

Observing for changes in urinary patterns, such as a sudden decrease in urinary output or frequent, small amounts of voiding.

Assessing for reports of urinary hesitancy, dribbling of urine, straining, or a sensation of incomplete bladder emptying during urination.

Encouraging the client to drink large amounts of fluid in a short period to stimulate bladder emptying.

Applying pressure over the lower abdomen to force urine out of the bladder.

Evaluating for palpable bladder distention after voiding to assess incomplete bladder emptying.

Answer and Explanation

Correct Answer : A,B,E

A. Observing for changes in urinary patterns, such as a sudden decrease in urinary output or frequent, small amounts of voiding. This can indicate urinary retention, as frequent, small voids may suggest incomplete emptying of the bladder.

B. Assessing for reports of urinary hesitancy, dribbling of urine, straining, or a sensation of incomplete bladder emptying during urination. These symptoms are common in urinary retention, indicating that the client is having difficulty fully emptying the bladder.

C. Encouraging the client to drink large amounts of fluid in a short period to stimulate bladder emptying: This is incorrect, as overhydration can worsen urinary retention, especially in clients with an impaired ability to empty their bladder.

D. Applying pressure over the lower abdomen to force urine out of the bladder: This is incorrect and can cause harm, as it may increase the risk of bladder injury.

E. Evaluating for palpable bladder distention after voiding to assess incomplete bladder emptying.
A distended bladder after voiding suggests incomplete emptying and potential urinary retention.

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Correct Answer is B

Explanation

A. I should avoid alcohol completely to prevent another episode of pancreatitis: This is correct advice, as alcohol is a common cause of pancreatitis and should be avoided.

B. I can resume my high-fat diet once my symptoms improve. A high-fat diet can trigger another episode of pancreatitis, as fat stimulates pancreatic enzymes that can exacerbate the condition. The patient should follow a low-fat diet.

C. I should take my prescribed medications as directed to manage my symptoms: This statement is appropriate and reflects adherence to the treatment plan.

D. I need to follow up with my healthcare provider regularly to monitor my condition: This is also correct, as regular monitoring is essential to managing pancreatitis.

A. Frothy urine B. Hypertension C. Fish-type urine odor D. Mental confusion E. Lower abdominal pain F. Weak urine stream

Correct Answer is ["B","C","D","E"]

Explanation

A. Frothy urine: Frothy urine is typically associated with proteinuria, seen in nephrotic syndrome, not pyelonephritis.

B. Hypertension: Hypertension can occur due to kidney inflammation and impaired function in pyelonephritis.

C. Fish-type urine odor: A foul or fishy-smelling urine odor is often associated with a urinary tract infection, including pyelonephritis.

D. Mental confusion: Mental confusion can occur in elderly patients with pyelonephritis due to systemic infection or sepsis.

E. Lower abdominal pain: Lower abdominal pain can occur with pyelonephritis due to infection in the urinary tract.

F. Weak urine stream: A weak urine stream is more characteristic of lower urinary tract issues, such as benign prostatic hyperplasia (BPH), rather than pyelonephritis.

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When caring for older adult clients at a long-term care facility, which of the following assessments should the nurse prioritize when evaluating for the risk and presence of urinary retention? (Select all that apply.)

Nursing Test Bank

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Correct Answer is B

Explanation

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Correct Answer is ["B","C","D","E"]

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