The nurse is visiting the client who has a nursing diagnosis of urinary retention. Upon assessment the nurse anticipates that this client will exhibit:

Question

1. Severe flank pain and hematuria
2. Pain and burning on urination
3. A loss of the urge to void
4. A feeling of pressure and voiding of small amounts

Answer 1

ANS: 4
With urinary retention, urine continues to collect in the bladder, stretching its walls and causing feelings of pressure, discomfort, tenderness over the symphysis pubis, restlessness, and diaphore-sis. The sphincter temporarily opens to allow a small volume of urine (25 to 60 mL) to escape, with no real relief of discomfort. Severe flank pain and hematuria are supporting data for an up-per urinary tract infection (pyelonephritis). Pain and burning on urination are symptoms of a low-er urinary tract infection (such as a bladder infection). Supportive data for reflex incontinence would include a loss of the urge to void.