A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?
Urinary retention
Urinary tract infection
Urinary incontinence
Urinary frequency
The Correct Answer is B
A. Urinary retention typically presents with difficulty urinating, rather than changes in urine color or odor.
B. Dark amber, cloudy urine with an unpleasant odor is indicative of a urinary tract infection (UTI). The cloudiness suggests the presence of bacteria or pus, while the dark color and odor are common signs of infection.
C. Urinary incontinence is characterized by the involuntary loss of urine, not changes in the characteristics of urine.
D. Urinary frequency refers to the need to urinate more often, which does not directly relate to the appearance or odor of the urine.
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Correct Answer is D
Explanation
A. Assessing the pedal pulses with a Doppler device is not necessary in this situation; the focus should be on the apical pulse due to the irregularity noted in the radial pulse.
B. Assessing the pedal pulses for a full minute does not address the irregularity of the radial pulse and is not the priority.
C. While assessing the apical pulse is appropriate, using a Doppler device is not required unless there are difficulties in obtaining the pulse normally.
D. Assessing the apical pulse for a full minute is the correct action because it provides a more accurate reflection of the heart's rhythm and rate, especially when there is an irregular radial pulse.
Correct Answer is A
Explanation
A. Using attentive listening with the client demonstrates the principle of presence by showing that the nurse is fully engaged and invested in the client's experience, fostering a collaborative relationship.
B. While focusing on the client’s present circumstances is important, the personal stories shared by clients can provide context and enhance understanding, so limiting this aspect is not ideal.
C. Offering personal thoughts and beliefs can shift the focus away from the client and is generally not appropriate in professional communication.
D. While verbalizing understanding is a supportive action, it does not fully encapsulate the principle of presence, which emphasizes active engagement and listening.