A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?
Palpate the right flank for tenderness.
Test the urine for the presence of hematuria.
Evaluate the urine for a strong odor.
Measure the temperature and pulse rate.
The Correct Answer is D
A. Palpating the right flank for tenderness is essential to assess for possible renal involvement, such as a kidney infection or kidney stone, which could be causing the urinary symptoms and right lower back pain. However, it is not the initial step.
B. Testing the urine for the presence of hematuria is important in assessing for potential urinary tract infection or other renal pathology but does not directly address the cause of the right lower back pain.
C. Evaluating the urine for a strong odor may provide information about a possible urinary tract infection, but it is not the most immediate intervention for addressing the client's symptoms, compared to measuring the vital signs.
D. Measuring the temperature and pulse rate is important for identifying any signs of systemic infection or inflammation that could be contributing to the patient's symptoms.
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Related Questions
Correct Answer is D
Explanation
A. Increasing anxiety may require intervention, but it does not pose an immediate threat to the client's health compared to other options.
B. Inappropriate laughter could indicate emotional lability, a common symptom in ALS, but it does not typically require immediate intervention unless it's accompanied by other concerning symptoms.
C. Asymmetrical weakness is common in ALS but may not necessarily warrant immediate intervention unless it is significantly affecting the client's ability to perform essential functions.
D. Weakened cough effort is a critical finding in a client with ALS, as it can lead to ineffective airway clearance and increase the risk of aspiration pneumonia. Immediate intervention, such as suctioning or respiratory support, may be necessary to maintain airway patency and prevent complications.
Correct Answer is D
Explanation
A. While using salt, herbs, and spices may enhance the flavor of foods, it does not specifically relate to self-management of type 2 diabetes mellitus.
B. Restricting alcoholic beverages is important in diabetes management, but the frequency and quantity recommended may vary based on individual factors and should be discussed with a healthcare provider.
C. Eating a protein snack before exercise can help stabilize blood sugar levels, but it should be consumed before and after exercise, not only before, to provide sustained energy.
D. Getting an influenza vaccine every year is a crucial aspect of diabetes self- management, as people with diabetes are at increased risk of complications from influenza. This demonstrates understanding of the importance of preventive care in managing diabetes.
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