The nurse is caring for a patient with benign prostatic hypertrophy who states that he feels a constant urge to urinate but cannot pass more than 30 to 60 mL of urine at a time. The nurse performs a bladder scan and finds that there are 1100 mL of urine in the patient's bladder. What is the priority nursing diagnosis for this patient?
A) Anxiety r/t continual urge to urinate
B) Reflex incontinence of urine r/t over-distention of the bladder
C) Impaired urination r/t obstruction of urinary bladder outlet
D) Impaired self-toileting r/t inability to pass urine into the toilet

Question

Quizplus · Accepted Answer

The patient has acute urinary retention with overflow as evidenced by 1100 mL of urine in the bladder and frequent passage of small amounts of urine. The priority nursing diagnosis is thus Impaired urination r/t obstruction of urinary bladder outlet. Urinary retention is the cause of the patient's discomfort and drainage of the bladder will result in relief of the patient's symptoms. The patient is able to get himself on and off the toilet so toileting self-care deficit is not a problem. Reflex incontinence of urine r/t over-distention of the bladder is not as specific to this scenario as the nursing diagnosis of impaired urination.

The Nurse Is Caring for a Patient with Benign Prostatic