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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 D

Explanation

A. The patients have lowered their cholesterol levels from previous laboratory results: Lower cholesterol levels are a positive health outcome but could result from factors other than weight loss, such as medication or diet changes. It is a good sign but not the most direct measure of the intervention's success.

B. The patients have improved blood pressure readings to be within expected reference range: Blood pressure improvements are important and can result from weight loss, but other factors like medications could influence this outcome.

C. The patients are choosing healthier food options for their diet plans: While choosing healthier food options is a positive behavior change, it is a process measure rather than an outcome. It does not necessarily indicate the interventions are working as effectively as a decrease in BMI.

D. There is a significant decrease in the patients' BMI measurements. A significant reduction in BMI is the most direct indicator of effective weight-loss interventions. A decrease in BMI reflects a measurable outcome that directly relates to weight loss.

A. Overdose B. Chronic Kidney Disease C. Hypertension D. Dehydration

Correct Answer is A

Explanation

A. Overdose: The patient has ingested a large quantity of unknown pills, leading to severe metabolic acidosis, high anion gap, and possible toxic accumulation. Dialysis is often indicated to clear toxins in the case of overdose, especially if renal function is impaired (as indicated by elevated creatinine).

B. Chronic Kidney Disease: While chronic kidney disease may eventually require dialysis, the acute overdose and metabolic acidosis are the more immediate concerns requiring urgent dialysis.

C. Hypertension: Hypertension may require management, but it is not the primary reason to initiate urgent dialysis in this scenario. The overdose and metabolic acidosis take precedence.

D. Dehydration: Dehydration alone does not necessitate dialysis. However, the overdose, metabolic acidosis, and renal impairment are the critical reasons for initiating dialysis.

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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 D

Explanation

Correct Answer is A

Explanation

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