Question

a nurse is caring for a client who is receiving antihistamine therapy for motion sickness and reports experiencing difficulty urinating. the nurse recognizes this as a potential anticholinergic side effect of the medication. which of the following actions should the nurse take?

• advise the client to discontinue the medication
• instruct the client to perform pelvic floor exercises
• encourage the client to drink cranberry juice
• check the client’s bladder for distention

Explanation:

• Discontinuing the medication without provider approval is unsafe, so the first option is incorrect.
• Pelvic floor exercises do not address anticholinergic-induced urinary retention, so the second option is incorrect.
• Cranberry juice supports urinary tract health but does not resolve this medication-related issue, so the third option is incorrect.
• Anticholinergic side effects can cause urinary retention, which presents with bladder distention. Assessing for distention is the priority nursing action to evaluate the severity of the issue before implementing further interventions.

Answer:

Check the client's bladder for distention