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A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?
- A. “Do you feel like you need to go to the bathroom?”
- B. “Are you able to walk to the bathroom by yourself?”
- C. “When was the last time you took your medicine?” NursingStoreRN
- D. “Do you have a safety rail in your bathroom at home?”
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Asking if the patient feels the need to go to the bathroom helps assess urgency.
2. Urinary retention may lead to the inability to sense the urge to void.
3. This question directly addresses the issue of voiding, crucial in diagnosing urinary retention.
Summary:
B: Mobility is not directly related to urinary retention.
C: Medication timing is important but not directly related to urinary retention.
D: Safety rail inquiry is more related to fall prevention, not urinary retention.
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Correct Answer: A
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- B. Pulmonary capillary pressure
- C. Transudation of fluid
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Correct Answer: D
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- B. Fruits and green vegetables
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Correct Answer: D
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- D. he no longer experiences perianal burning
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Correct Answer: A
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