A nurse is assessing a client who has urinary retention.
Which of the following findings should the nurse expect?
Blood in urine.
Cloudy urine.
Dark-colored urine.
Leakage of urine.
The Correct Answer is D
Choice A rationale
Blood in the urine (hematuria) is not a typical finding in urinary retention. It may indicate other conditions such as infection, stones, or malignancy.
Choice B rationale
Cloudy urine is often a sign of infection, not typically associated with urinary retention. It can be caused by the presence of bacteria, white blood cells, or crystals.
Choice C rationale
Dark-colored urine can result from dehydration or certain foods and medications. It is not a specific finding of urinary retention.
Choice D rationale
Leakage of urine, also known as overflow incontinence, can occur in urinary retention. This happens when the bladder becomes overly full, and small amounts of urine leak out due to the pressure.
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Correct Answer is B
Explanation
Choice A rationale
Aluminum-containing antacids often cause constipation due to their effect on bowel motility, not diarrhea. They work by neutralizing stomach acid but can lead to decreased bowel movements.
Choice B rationale
Magnesium-containing antacids can cause diarrhea as a side effect. They work by neutralizing stomach acid, and the excess magnesium in the intestines can cause loose stools or diarrhea.
Choice C rationale
Antibiotics can cause diarrhea by disrupting the balance of normal gut bacteria. This disruption can lead to overgrowth of harmful bacteria, such as Clostridium difficile, which can cause diarrhea.
Choice D rationale
Anticholinergics/antispasmodics typically cause constipation rather than diarrhea. They inhibit the parasympathetic nervous system, which slows down gut motility.
Choice E rationale
Opioid narcotics can cause constipation because they slow down the movement of the intestines. They do this by binding to opioid receptors in the gut, which decreases peristalsis.
Correct Answer is D
Explanation
Choice A rationale
Instilling ophthalmic medication directly on the cornea can cause irritation and discomfort. Medications should be administered in the conjunctival sac.
Choice B rationale
Asking the client to tightly squeeze their eyes shut after instillation can expel the medication, reducing its effectiveness. Gentle closing of the eyes is recommended.
Choice C rationale
Cleaning the eye from the outer canthus to the inner canthus is not the proper method. The correct method is to clean from the inner canthus to the outer canthus to avoid contaminating the inner eye.
Choice D rationale
Applying pressure to the nasolacrimal duct after instillation helps prevent the medication from draining into the nasolacrimal system, ensuring better absorption in the eye.