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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. Intestinal obstruction: While peritonitis can lead to intestinal obstruction, it is not the most immediate life-threatening complication compared to hypovolemic shock or sepsis.

B. Hypovolemic shock: This is a critical condition that can occur due to severe fluid loss, which might be a concern in peritonitis due to fluid shifts into the abdominal cavity. However, the patient’s signs of systemic infection (fever, elevated heart rate, low blood pressure) suggest that sepsis is a more imminent threat.

C. Electrolyte imbalance: Electrolyte imbalances are possible due to fluid loss, but they would be secondary to the more urgent concern of hypovolemic shock.

D. Sepsis: Sepsis is the highest priority due to the patient’s vital signs and symptoms indicating a systemic infection. Early recognition and treatment of sepsis are crucial to prevent organ failure and other severe complications.

A. Low back pain B. Confusion C. Urinary retention D. Incontinence

Correct Answer is B

Explanation

A. Low back pain: While this can be a symptom of a UTI, it is not unique to older adults and can be seen in various age groups.

B. Confusion: In older adults, UTIs often present with atypical symptoms, such as confusion or delirium, rather than the classic symptoms like dysuria or frequency. This can be a sign of infection in this population.

C. Urinary retention: This is not specific to UTIs in older adults and can occur for other reasons, such as benign prostatic hyperplasia (BPH).

D. Incontinence: Although older adults may experience incontinence, it is not a unique sign of UTI and could be related to other conditions like weakened pelvic muscles.

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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.)

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Correct Answer is B

Explanation

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Correct Answer is B

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