Nokea
The nurse is preparing the plan of care for the client diagnosed with a neurogenic flaccid bladder. Which expected outcome is appropriate for this client?
- A. The client has conscious control over bladder activity.
- B. The client’s bladder does not become overdistended.
- C. The client has bladder sensation and no discomfort.
- D. The client demonstrates how to check for bladder distention.
Correct Answer: B
Rationale: A neurogenic flaccid bladder lacks tone, risking overdistention. Preventing this is a key outcome to avoid complications like infection or reflux. Conscious control and sensation are unlikely, and checking distention is an intervention.
You may also like to solve these questions
The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented?
- A. Encourage fluids orally.
- B. Administer 10% saline solution IVPB.
- C. Administer antidiuretic hormone intranasally.
- D. Place on seizure precautions.
Correct Answer: D
Rationale: Severe hyponatremia (110 mEq/L) increases seizure risk due to cerebral edema. Seizure precautions are the priority to ensure safety. Oral fluids or ADH may worsen hyponatremia, and 10% saline is not standard.
Which information should the nurse include when explaining the management of the client's urolithiasis? Select all that apply.
- A. Increase fluid intake to 3 liters per day.
- B. Strain all urine to collect stones for analysis.
- C. Take prescribed analgesics for pain relief.
- D. Avoid all dairy products to prevent stone formation.
- E. Follow a low-sodium diet to reduce stone risk.
- F. Report fever or chills immediately.
Correct Answer: A,B,C,F
Rationale: Increasing fluid intake, straining urine, taking analgesics, and reporting fever or chills are key management strategies for urolithiasis to promote stone passage and prevent complications.
Which nursing diagnosis is priority for the client who has undergone a TURP?
- A. Potential for sexual dysfunction.
- B. Potential for an altered body image.
- C. Potential for chronic infection.
- D. Potential for hemorrhage.
Correct Answer: D
Rationale: Hemorrhage is the priority post-TURP due to the risk of significant bleeding from the surgical site, which can be life-threatening. Sexual dysfunction, body image, and infection are secondary concerns.
The client is in the intensive care department (ICD) after a motor-vehicle accident in which the client lost an estimated three (3) units of blood. Which action by the nurse could prevent the client from developing acute renal failure?
- A. Take and document the client’s vital signs every hour.
- B. Assess the client’s dressings every two (2) hours.
- C. Check the client’s urinary output every shift.
- D. Maintain the client’s blood pressure greater than 100/60.
Correct Answer: D
Rationale: Significant blood loss risks prerenal ARF due to hypoperfusion. Maintaining BP above 100/60 ensures adequate renal perfusion. Vital signs, dressing checks, and urine output monitoring are supportive but less preventive.
The nurse is caring for the client recovering from a percutaneous renal biopsy. Which data indicate the client is complying with client teaching?
- A. The client is lying flat in the saline position.
- B. The client continues oral fluids restriction while on bedrest.
- C. The client uses the bedside commode to urinate.
- D. The client refuses to ask for any pain medication.
Correct Answer: A
Rationale: Post-renal biopsy, lying flat (supine, assuming 'saline' is a typo) prevents bleeding complications, indicating compliance. Fluid restriction is unnecessary, using a commode risks bleeding, and refusing pain meds is unrelated.