The nurse is placing an indwelling urinary catheter in an uncircumcised male patient and replaces the foreskin after insertion. What is the rationale for this nursing action?
1. Paraphimosis may result from long-term retraction of the foreskin, causing ischemia of the glans.
2. Phimosis may occur due to chronic infections and adhesions under the foreskin, which results in constriction of the foreskin.
3. Priapism may occur as a result of impaired blood flow in the penis.
4. Replacement of the foreskin prevents malignant changes in the penis.
1
Rationale 1: Paraphimosis may occur as a result of long-term retraction of the foreskin and cause ischemia of the glans.
Rationale 2: The foreskin may not be retracted in the patient with phimosis due to the constriction resulting from chronic infections and adhesions. The nurse should not attempt this action during catheterization.
Rationale 3: Priapism occurs with sustained painful erections that impair blood flow in the penis. It does not involve the foreskin.
Rationale 4: Phimosis, or tight foreskin, can prevent adequate hygiene, which may lead to malignant changes in the penis.
You might also like to view...
What is the leading cause of death of infants over 1 month of age?
a. congenital heart disease c. physical abuse b. meningitis d. sudden infant death syndrome
A child diagnosed with expressive language disorder has a nursing diagnosis of impaired verbal communication. Which of the following nursing interventions would be most appropriate?
A) Maintain consistency of caregivers. B) Allow the child ample time to communicate. C) Identify capabilities of the child related to self-care. D) Establish a consistent pattern of reward for positive behavior.
One of your staff nurses asks for your advice because a patient refuses to sign a consent for surgery. The patient says that he won't sign because he doesn't understand the nature of the surgery. You advise that (select all that apply):
a. Consent must not be coerced. b. The patient has a right to choose not to consent. c. The patient must sign the consent because the doctor wants him to sign. d. Witnessing a consent is related only to the voluntary nature of the signature.
The client with cellulitis of the lower leg has had cultures done on the affected area. The nurse reviewing the results of the culture report interprets that which of the following organisms is not part of the normal flora of the skin?
1. Escherichia coli 2. Candida albicans 3. Staphylococcus aureus 4. Staphylococcus epidermidis