The nurse is caring for a patient with benign prostatic hypertrophy who states that he feels a constant urge to urinate but cannot pass more than 30 to 60 mL of urine into the toilet at a time

Question

The nurse performs a bladder scan and finds that there are 1100 mL of urine in the patient's bladder. What is the priority nursing diagnosis for this patient?
a.
Alteration in comfort r/t continual urge to urinate
b.
Overflow urinary incontinence r/t over-distention of the bladder
c.
Urinary retention r/t obstruction of urinary bladder outlet
d.
Toileting self-care deficit r/t inability to pass urine into the toilet

Answer 1

ANS: C
The patient has acute urinary retention with overflow as evidenced by 1100 mL of urine in the bladder and frequent passage of small amounts of urine. The priority nursing diagnosis is thus urinary retention r/t obstruction of urinary bladder outlet. Urinary retention is the cause of the patient's discomfort and drainage of the bladder will result in relief of the patient's symptoms. The patient is able to get himself on and off the toilet so toileting self-care deficit is not a problem. Overflow urinary incontinence is not applicable because the patient is passing the urine into the toilet.