Which action would the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?
Assist the patient to the commode every 2 hours.
Teach the patient how to self-catheterize.
Suggest the use of adult incontinence briefs.
Encourage decreased evening fluid intake.
The Correct Answer is B
Choice A reason: Assisting to the commode every 2 hours doesn’t address flaccid bladder retention, as the patient cannot void. Self-catheterization empties the bladder, making this incorrect, as it’s ineffective compared to the nurse’s plan for managing urinary retention in multiple sclerosis.
Choice B reason: Teaching self-catheterization enables a patient with a flaccid bladder from multiple sclerosis to empty the bladder, preventing retention complications. This aligns with neurogenic bladder management, making it the correct action the nurse would plan for effective urinary care.
Choice C reason: Incontinence briefs manage overflow but don’t address retention, risking infections. Self-catheterization is needed, making this incorrect, as it’s inappropriate compared to the nurse’s focus on actively emptying the bladder in a patient with multiple sclerosis.
Choice D reason: Decreasing evening fluid intake reduces urine volume but doesn’t solve retention from a flaccid bladder. Self-catheterization is key, making this incorrect, as it fails to address the nurse’s goal of managing urinary retention effectively in multiple sclerosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A reason: Excessive oral fluid intake from thirst doesn’t cause ascites, which results from liver dysfunction. Portal hypertension is a cause, making this incorrect, as it misattributes ascites to fluid intake rather than the nurse’s understanding of cirrhosis-related fluid shifts.
Choice B reason: Portal hypertension in cirrhosis increases pressure, pushing proteins into the peritoneal cavity, causing ascites. This aligns with liver pathophysiology, making it a correct cause the nurse would identify for ascites in a patient with liver cirrhosis.
Choice C reason: Decreased albumin synthesis in cirrhosis reduces colloid oncotic pressure, leading to fluid leakage into the peritoneal cavity, causing ascites. This aligns with liver dysfunction, making it a correct cause the nurse would recognize in cirrhosis-related ascites.
Choice D reason: Poor nutrition may cause weight loss, not ascites, which is fluid accumulation from liver issues. Low albumin is a cause, making this incorrect, as it misidentifies the nurse’s expected mechanisms for ascites in liver cirrhosis patients.
Correct Answer is C
Explanation
Choice A reason: Hypotension, chills, and thirst are not specific to thyroid storm, which presents with hypermetabolic symptoms like fever and tachycardia. These symptoms may relate to other conditions, making this incorrect, as it doesn’t match the nurse’s expected findings for thyroid storm in a hyperthyroid client requiring urgent care.
Choice B reason: Bradycardia and low urine output suggest hypothyroidism or hypovolemic shock, not thyroid storm, which is characterized by hyperdynamic signs like tachycardia. This is incorrect, as it contradicts the nurse’s recognition of thyroid storm’s hallmark symptoms, such as fever and tremors, in hyperthyroidism.
Choice C reason: Fever, tachycardia, and tremors are classic indicators of thyroid storm, a life-threatening hyperthyroidism complication caused by excessive thyroid hormone, leading to hypermetabolism. This aligns with endocrine emergency assessment, making it the correct set of symptoms the nurse would identify in this client.
Choice D reason: Lethargy, confusion, and bradycardia are associated with hypothyroidism or other conditions, not the hypermetabolic state of thyroid storm. Fever and tachycardia are key, making this incorrect, as it misaligns with the nurse’s expected symptoms for a hyperthyroidism-related emergency like thyroid storm.
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