A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?

A) "Do you feel like you need to go to the bathroom?"
B) "Are you able to walk to the bathroom by yourself?"
C) "When was the last time you took your medicine?"
D) "Do you have a safety rail in your bathroom at home?"

The nurse must establish that the patient feels the urge and is unable to void. The question "Do you feel like you need to go to the bathroom?" is the most appropriate to ask. This question can be ansed without knowledge of the diagnosis of Urinary retention. Discussing the ability to walk to the bathroom and asking about safety rails pertain to mobility and safety issues, not to retention of urine. Taking certain medications may lead to urinary retention, but that information would establish the etiology. The question is asking for the nurse to first establish the correct diagnosis.