The nurse is visiting the client who has a nursing diagnosis of Alteration in urinary elimination, retention. On assessment, the nurse anticipates that this client will exhibit which of the following symptoms?
a. Severe flank pain and hematuria
b. Pain and burning on urination
c. A loss of the urge to void
d. A feeling of pressure and voiding of small amounts
D
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 diapho-resis. The sphincter temporarily opens to allow a small volume of urine (< 75 mL) to escape, with no real relief of discomfort.
Severe flank pain and hematuria are supporting data for an upper UTI (pyelonephritis).
Pain and burning on urination are symptoms of a lower UTI (such as a bladder infection).
Supportive data for reflex incontinence would include a loss of the urge to void.
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