Which goals should the nurse identify as appropriate for a client with

Which goals should the nurse identify as appropriate for a client with the nursing diagnosis Urinary Pattern Alteration related to an enlarged prostate?

1. The client will avoid bladder distention.
2. The client will maintain fluid imbalance.
3. The client will remain free of skin breakdown.
4. The client will voice increased discomfort.

ANSWER

Correct Answer: 1
Rationale 1: Avoiding bladder distention will help eliminate stasis of urine in the bladder, which contributes to urinary tract infections, a possible complication of urine flow being obstructed from an enlarged prostate.
Rationale 2: One would want to maintain fluid balance, not imbalance, with a client with urinary obstruction and enlarged prostate. Keeping up with the client’s intake and output would be a better goal.
Rationale 3: It is important to keep urine off the skin to prevent breakdown, but with an enlarged prostate the problem will be more of the client retaining urine instead of it being on the skin.
Rationale 4: One would hope that if the retention subsides, the client would voice less discomfort, not more.