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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Monitoring potassium levels is essential for various medical conditions, but it is not specifically used to evaluate the effects of therapy for acute pancreatitis. Potassium levels may be monitored to assess overall electrolyte balance and kidney function, but they do not provide direct information about pancreatic inflammation or damage.
Choice B reason: Monitoring lipase levels is crucial in evaluating the effects of therapy for a patient with acute pancreatitis. Lipase is an enzyme produced by the pancreas, and its levels rise significantly during an acute episode of pancreatitis. Elevated lipase levels are a sensitive and specific indicator of pancreatic inflammation and damage. By regularly measuring lipase levels, healthcare providers can assess the severity of the condition, monitor the patient's response to treatment, and make necessary adjustments to the therapeutic regimen.
Choice C reason: Calcium levels are not typically used to evaluate the effects of therapy for acute pancreatitis. Although hypercalcemia (high calcium levels) can be a risk factor for developing pancreatitis, monitoring calcium levels is not a standard method for assessing the effectiveness of treatment for the condition.
Choice D reason: Bilirubin levels are not directly related to the evaluation of therapy for acute pancreatitis. Bilirubin is a breakdown product of hemoglobin and is primarily used to assess liver function and diagnose conditions such as jaundice or liver disease. While liver function tests may be performed in patients with pancreatitis to rule out concurrent liver issues, bilirubin levels alone do not provide information about the effectiveness of therapy for pancreatitis.
Correct Answer is ["C","E","F"]
Explanation
Choice A reason: Applying a clean, dry dressing over the VTE/DVT site is not necessary. VTE/DVT usually involves deep veins where there are no visible wounds requiring dressings. This instruction is irrelevant to the management and discharge instructions for a patient with DVT on anticoagulant therapy.
Choice B reason: Monitoring activated partial thromboplastin time (aPTT) results is relevant for heparin therapy, not for warfarin. Warfarin therapy is monitored using the international normalized ratio (INR). Therefore, this instruction is not appropriate for a patient being discharged on warfarin.
Choice C reason: Administering the warfarin dose at the same time each day is crucial for maintaining consistent blood levels of the medication, ensuring its effectiveness. It helps to maintain steady anticoagulation and reduces the risk of complications associated with fluctuating blood levels of warfarin.
Choice D reason: Instructing the patient to take aspirin or NSAIDs as needed for pain is inappropriate because these medications can increase the risk of bleeding when taken with warfarin. Patients on warfarin should avoid these medications and use alternatives like acetaminophen (Tylenol) for pain relief.
Choice E reason: Advising the patient to use electric razors, not straight razors, when shaving is important to prevent cuts and bleeding. Warfarin increases the risk of bleeding, and using an electric razor minimizes the chance of nicks and cuts that could lead to significant bleeding.
Choice F reason: Monitoring the level of anticoagulation with warfarin using INR results is essential. Regular INR monitoring ensures that the patient maintains a therapeutic level of anticoagulation and helps prevent both clotting and bleeding complications. Adjustments to the warfarin dose are made based on INR results.
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