Which action should the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?

Suggest the use of adult incontinence briefs for nighttime only.

Assist the patient to the commode every 2 hours during the day.

Teach the patient how to self-catheterize.

Encourage decreased evening intake of fluid.

Answer and Explanation

The Correct Answer is C

Choice A reason: Suggesting the use of adult incontinence briefs for nighttime only may help manage incontinence during the night, but it does not address the primary issue of urinary retention caused by a flaccid bladder. Incontinence briefs are a passive approach and do not prevent urinary retention or the complications associated with it, such as urinary tract infections and kidney damage. Additionally, it does not empower the patient to actively manage their urinary retention.
Choice B reason: Assisting the patient to the commode every 2 hours during the day can help to some extent in managing urinary retention. However, this approach requires constant assistance and is not practical for long-term management, especially when the patient is alone or in settings where frequent assistance is not available. This method also does not ensure complete bladder emptying, which is crucial for preventing urinary tract infections and other complications.
Choice C reason: Teaching the patient how to self-catheterize is the most appropriate and effective action for managing urinary retention caused by a flaccid bladder. Self-catheterization allows the patient to empty the bladder regularly and completely, reducing the risk of urinary tract infections, bladder distention, and kidney damage. It also provides the patient with a sense of control and independence in managing their condition. Self-catheterization is a standard and recommended practice for individuals with neurogenic bladder dysfunction due to multiple sclerosis.
Choice D reason: Encouraging decreased evening intake of fluid can help reduce nighttime urination, but it does not address the issue of urinary retention caused by a flaccid bladder. Decreasing fluid intake is not a comprehensive solution and does not prevent complications associated with incomplete bladder emptying. It is important to manage fluid intake appropriately, but this should be part of a broader strategy that includes effective bladder emptying techniques like self-catheterization.

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Correct Answer is B

Explanation

Choice A reason: Aggressive physical therapy is not a treatment for Addison's disease. While physical therapy can be beneficial for certain conditions, it does not address the hormonal deficiencies that are characteristic of Addison's disease.
Choice B reason: Lifelong hormone therapy with glucocorticoids and mineralocorticoids is the standard treatment for Addison's disease. This involves taking medications to replace the hormones that the adrenal glands are not producing enough of, specifically glucocorticoids (such as hydrocortisone, prednisone, or dexamethasone) and mineralocorticoids (such as fludrocortisone). These medications help to maintain normal hormone levels in the body, manage symptoms, and prevent adrenal crises.
Choice C reason: Diuretics are not typically used as a primary treatment for Addison's disease. They are used to manage fluid balance and blood pressure in other conditions, but they do not replace the deficient hormones in Addison's disease.
Choice D reason: Lifelong insulin treatment is used for managing diabetes mellitus, not Addison's disease. Addison's disease involves adrenal hormone deficiencies, which are treated with hormone replacement therapy, not insulin.

A. Jaundice B. Spider angiomas C. Lethargic D. Apical pulse regular with S1, S2 E. Abdomen moderately distended F. Dark amber urine G. Peripheral pulses are palpable H. 3+ pitting edema

Correct Answer is ["A","B","E","F","H"]

Explanation

Choice A reason: Jaundice is a common finding in cirrhosis due to impaired liver function, which leads to the accumulation of bilirubin in the blood. This causes the skin and the whites of the eyes to turn yellow.
Choice B reason: Spider angiomas are dilated blood vessels that appear on the skin and are often seen in patients with cirrhosis. They are caused by increased estrogen levels due to impaired liver function.
Choice C reason: Lethargy is a symptom of cirrhosis as the liver's ability to detoxify the blood is compromised, leading to fatigue and weakness.
Choice D reason: An apical pulse regular with S1, S2 is not specifically associated with cirrhosis. While it may be a normal finding, it does not indicate the presence of cirrhosis.
Choice E reason: Abdomen moderately distended is consistent with cirrhosis due to the accumulation of fluid in the abdominal cavity (ascites), which is a common complication of advanced liver disease.
Choice F reason: Dark amber urine is a sign of cirrhosis as the liver's ability to process bilirubin is impaired, leading to the excretion of conjugated bilirubin in the urine, which gives it a dark color.
Choice G reason: Peripheral pulses are palpable is not specifically associated with cirrhosis. While it may be a normal finding, it does not indicate the presence of cirrhosis.
Choice H reason: 3+ pitting edema is consistent with cirrhosis due to the retention of sodium and water, leading to swelling in the lower extremities.

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Which action should the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

How is Addison disease treated and clinically managed?

Correct Answer is B

Explanation

Which assessment findings are consistent with cirrhosis? Select all that apply.

Correct Answer is ["A","B","E","F","H"]

Explanation

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