The nurse notes that a patient who has a large cystocele, admitted 10 hours ago, has not yet voided. Which action should the nurse take first?
a. Insert a straight catheter per the PRN order.
b. Encourage the patient to increase oral fluids.
c. Notify the health care provider of the inability to void.
d. Use an ultrasound scanner to check for urinary retention.
ANS: D
Because urinary retention is common with a large cystocele, the nurse's first action should be to use an ultrasound bladder scanner to check for the presence of urine in the bladder. The other actions may be appropriate, depending on the findings with the bladder scanner.
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The nurse plans to encourage an anxious patient to talk about his feelings and concerns. The rationale for this intervention is that:
a. talking serves as constructive distraction and reduces the patient's anxiety. b. stating concerns aloud becomes less overwhelming and promotes problem solving. c. focusing on and validating what is occurring in the environment reduces anxiety. d. exploring feelings reduces one's sense of powerlessness and lessens anxiety.
The 48-year-old client with diabetes mellitus is being treated for her third episode of acute pyelonephritis in the past year. She asks what she could do to help prevent these infections. What is the nurse's best response?
A. "Test your urine daily for the presence of ketone bodies and proteins." B. "Use tampons rather than sanitary napkins during your menstrual period." C. "Drink more water and try to empty your bladder at least every 2 to 3 hours while you are awake." D. "Inject your insulin in larger doses or more frequently to keep your blood sugar lower so the microorganisms have fewer nutrients for growth."
Warren's college roommate actively resists going out with friends whenever they invite him. He says he can't stand to be around other people and confides to Warren "They wouldn't like me anyway." Which disorder is Warren's roommate likely suffering from?
A. Agoraphobia B. Mysophobia C. Social anxiety disorder (social phobia) D. Panic disorder
After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence of which of the following complications related to pelvic surgery?
a) Peritonitis. b) Thrombophlebitis. c) Ascites. d) Inguinal hernia.