The nurse is caring for a patient with urinary retention. Which measures should the nurse take when assisting the patient to void? (Select all that apply)

Urinary retention is the inability to empty the bladder, often caused by obstruction, sensory-motor dysfunction, or psychological factors. Nursing interventions focus on promoting relaxation of the pelvic floor and the external urinary sphincter while utilizing sensory stimuli to trigger the micturition reflex and facilitate spontaneous voiding. A. Applying cold compresses to the perineum would likely cause muscle contraction and vasoconstriction, which would exacerbate urinary retention. Warmth is preferred because it promotes vasodilation and muscle relaxation, making it easier for the patient to initiate the flow of urine. B. Providing assistance to the toilet ensures patient safety and encourages a normal anatomical position for voiding. For many patients, being in a familiar environment (the bathroom) rather than using a bedpan can reduce the anxiety and physical difficulty associated with attempting to void while hospitalized. C. The sound of running water is a classic sensory trick used to stimulate the micturition reflex. This auditory stimulus can trigger a psychological response that encourages the detrusor muscle to contract and the urinary sphincter to relax, helping the patient overcome the initial difficulty of starting a stream. D. A warm sitz bath provides localized heat to the pelvic and perineal areas. This warmth helps relax the muscles of the urinary tract and the external sphincter. It is particularly effective for patients whose retention is caused by postoperative pain, inflammation, or pelvic floor tension. E. Offering tea or soda is inappropriate. Both of these beverages contain caffeine, which is a known bladder irritant and can cause urinary urgency or frequency without necessarily assisting in the complete emptying of the bladder. Furthermore, carbonated beverages can irritate the bladder mucosa, which is unhelpful for a patient already experiencing retention.