Which of the following is a potential complication of urinary retention in immobile clients?
Muscle weakness
Dehydration
Bladder shrinkage
Urinary tract infection (UTI)
The Correct Answer is D
A. Muscle weakness is a systemic effect of immobility and deconditioning rather than a direct complication of urinary retention. While the inability to ambulate to the bathroom may contribute to retention, the physiological process of retaining urine does not impact skeletal muscle fiber recruitment. The two conditions are independent clinical consequences of a sedentary or bedridden state.
B. Dehydration is a fluid volume deficit that results from inadequate intake or excessive loss of fluids. Urinary retention involve the inability to empty the bladder despite the presence of urine, which is a problem of elimination rather than intake. While poor fluid intake might decrease urine production, it does not cause the mechanical failure of bladder emptying.
C. Chronic urinary retention leads to the overdistension and stretching of the bladder wall (detrusor muscle) rather than shrinkage. This persistent stretching can result in a loss of bladder tone and decreased contractility over time. Bladder shrinkage, or reduced capacity, is more commonly associated with chronic inflammatory conditions or the long-term use of indwelling catheters.
D. Urinary retention is a significant risk factor for the development of a urinary tract infection (UTI). When urine remains stagnant in the bladder, it provides a warm, dark environment that facilitates the rapid colonization and multiplication of bacteria. This stasis allows pathogens to ascend the ureters or irritate the bladder mucosa, leading to clinical infection and potential urosepsis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A.Criteria for obtaining and maintaining nursing licensure are established by state laws and regulated by the State Board of Nursing via the Nurse Practice Act. The Code of Ethics provides a moral framework for practice but does not contain the legal requirements for entry into the profession. It serves as a guide for conduct rather than a statute for licensing.
B.Student nurses are absolutely held to the same ethical standards as licensed professionals from the moment they begin their clinical education. Accountability to the Code of Ethics is a requirement for anyone assuming the nursing role, regardless of their current student status. Maintaining professional boundaries and patient confidentiality is a non-negotiable expectation for all individuals in the nursing program.
C.Modern iterations of the Code of Ethics explicitly address contemporary issues such as the use of social media and the maintenance of digital boundaries. The COE emphasizes that nurses must protect patient privacy and professional integrity across all communication platforms, including the internet. Failing to follow these guidelines can result in professional discipline and a loss of public trust.
D.Professional expectations, such as the duty to provide non-judgmental care and the obligation to act as a patient advocate, are core components of the Code of Ethics. The COE serves as a non-negotiable professional standard that outlines the values and duties of the nursing profession. It informs the nurse’s responsibility to the patient, the public, and the healthcare team.
Correct Answer is C
Explanation
A.Nursing diagnoses are primarily derived from the systematic analysis of assessment data and clinical evidence using standardized taxonomies like NANDA-I. While Maslow's theory helps understand human motivation, it is not the primary tool for identifying specific pathological or functional nursing problems. Accurate diagnoses require a focus on the patient's unique physiological and psychosocial responses to health.
B.Concisely communicating clinical concerns is a skill related to professional reporting frameworks, such as SBAR (Situation, Background, Assessment, Recommendation). While a nurse may prioritize what to communicate based on a patient's needs, Maslow's hierarchy itself is not a communication protocol. It provides the rationale for the order of care rather than a method for verbal or written reporting.
C.Maslow's hierarchy of needs provides a vital framework for establishing priorities of care by identifying which patient needs are most urgent for survival. Physiological needs, such as oxygenation and hydration, must be addressed before higher-level needs like self-esteem or self-actualization. This helps the nurse organize their workflow and ensure that life-sustaining interventions are prioritized in a complex clinical environment.
D.Integrating science into nursing care involves the application of biology, chemistry, and pharmacology through evidence-based practice and research. Maslow's hierarchy is a psychological and humanistic theory rather than a hard science or clinical protocol. While it informs the humanistic side of nursing, it does not serve as the primary vehicle for integrating scientific research into technical bedside care.
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