Author Question: Which nursing diagnosis would be appropriate for a client who has a retention catheter if the ... (Read 31 times)

crazycityslicker · **on:** Jul 23, 2018

Which nursing diagnosis would be appropriate for a client who has a retention catheter if the drainage bag is found lying on the floor?

1. Risk for Impaired Skin Integrity related to catheter placement
2. Risk for Infection related to improper handling
3. Self-Care Deficit related to presence of a retention catheter
4. Risk for Incontinence related to an obstruction

Question 2

The nurse is identifying outcomes for a client with the nursing diagnosis Stress Urinary Incontinence. Which outcome would be related to sphincter incompetence?

1. The client will empty her bladder every time she voids.
2. The client will improve her incontinence within 1 month.
3. The client will perform four to five squeezes for 5 to 10 seconds.
4. The client will stop the flow of urine when voiding.

yuyiding · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 2
Rationale 1: There is a possibility of skin impairment with a catheter, but the emphasis here is on where the drainage bag was found.
Rationale 2: The floor is the dirtiest place, so the drainage device should never be placed on the floor.
Rationale 3: Even though a client has a catheter in place, it does not restrict one from providing self-care. The client may need some assistance.
Rationale 4: The placement of a catheter prevents incontinence; it does not add to it. Patency of the catheter ensures flow, not obstruction.

Answer to Question 2

Correct Answer: 3
Rationale 1: Emptying the bladder completely every time she voids would not be realistic in the beginning. This will take time.
Rationale 2: Improved continence takes 3 to 6 months, so 1 month is not a realistic goal.
Rationale 3: Performing four to five squeezes for 5 to 10 seconds is the goal to start with when teaching a client Kegel exercises, which are used for stress and urge incontinence.
Rationale 4: Clients are not instructed to stop the flow of urine when voiding because this could lead to retention.