A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?
a. "Do you feel like you need to use the bathroom?"
b. "Are you able to walk to the bathroom by yourself?"
c. "When was the last time you took your medicine?"
d. "Do you have a safety rail in your bathroom at home?"
ANS: A
The nurse must establish that the patient feels the urge and is unable to void. The question "Do you feel like you need to use the bathroom?" is the most appropriate to ask. This question can be answered without knowledge of the diagnosis of Urinary retention. Discussing the ability to walk to the bathroom and asking about safety rails pertain to mobility and safety issues, not to retention of urine. Taking certain medications may lead to urinary retention, but that information would establish the etiology. The question is asking for the nurse to first establish the correct diagnosis.
You might also like to view...
A client is admitted to the acute care facility from a homeless shelter. The day after the admission, the client becomes unresponsive and experiences cardiac arrest
The nurse caring for the client reports there is no order to withhold resuscitative efforts. Which of the following actions is indicated first? A) Resuscitation must be initiated. B) The homeless shelter must be notified. C) The admitting physician must be notified. D) The shift supervisor must be notified.
Which of the following vitamins turns urine yellow in color?
1. Vitamin B2 2. Vitamin B3 3. Vitamin B1 4. Vitamin B6
The nurse is monitoring a client with liver failure. Which assessments does the nurse perform when monitoring for bleeding in this client? (Select all that apply.)
a. Gums b. Lung sounds c. Urine d. Stool e. Hair
A client's ECG tracing shows normal sinus rhythm followed by a complex of three PVCs, with a return to normal sinus rhythm. What is the nurse's interpretation of this finding?
A. Nonsustained ventricular tachycardia B. Ventricular escape rhythm C. Atrial flutter D. Trigeminy