A female college student comes to the school's health clinic reporting urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

Test her urine for the presence of haematuria.

Measure her temperature and heart rate.

Evaluate the urine for a strong Odor.

Palpate the right flank for tenderness.

Answer and Explanation

The Correct Answer is B

Choice A reason: Testing the urine for the presence of haematuria is important for diagnosing a urinary tract infection (UTI) or kidney stones, but it is not the most immediate intervention. Haematuria indicates blood in the urine, but assessing the client's vital signs is more urgent to determine if there is an acute issue that requires immediate attention.

Choice B reason: Measuring her temperature and heart rate is the most critical first step. These vital signs can provide immediate information about the client's overall condition and help identify potential systemic infection (fever) or hemodynamic instability (tachycardia). This information is essential for prioritizing further interventions and determining the urgency of the situation.

Choice C reason: Evaluating the urine for a strong Odor can help identify the presence of a UTI, but it is not as immediately critical as assessing the client's vital signs. Changes in urine Odor can support a diagnosis, but they do not provide the urgent information needed to assess the client's immediate health status.

Choice D reason: Palpating the right flank for tenderness is important for assessing kidney involvement, such as in cases of pyelonephritis (kidney infection). However, this physical examination should follow the assessment of vital signs to ensure the client is stable and not in immediate danger.

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Correct Answer is B

Explanation

Choice A reason: Clay-coloured stool is a symptom of bile duct obstruction. It indicates that bile is not reaching the intestines to help digest food. While this is important to note, it is not the most urgent finding that requires immediate reporting to the healthcare provider.

Choice B reason: A distended, hard, and rigid abdomen is a sign of possible peritonitis or other severe abdominal complications. This finding indicates a medical emergency that requires immediate attention and intervention by the healthcare provider. Prompt reporting is essential to prevent further complications and ensure appropriate treatment.

Choice C reason: Bile-stained emesis suggests that bile is being regurgitated, which is indicative of a blocked or compromised bile duct. However, this finding does not require as urgent reporting as a rigid abdomen, which could indicate a more serious condition.

Choice D reason: Radiating, sharp pain in the right shoulder is often referred pain from gallbladder issues. While this symptom is significant and should be monitored, it does not take precedence over the urgent finding of a distended and rigid abdomen that might indicate a severe complication.

A. Drinks several bottles of carbonated water daily. B. Eats a vegetarian diet with cheese 2 to 3 times a day. C. Experiences additional stress since adopting a child. D. Jogs more frequently than usual daily routine.

Correct Answer is B

Explanation

Choice A reason: Drinking several bottles of carbonated water daily is not a well-established risk factor for renal calculi. While hydration is important in preventing kidney stones, carbonation itself does not significantly increase the risk.

Choice B reason: Eating a vegetarian diet with cheese 2 to 3 times a day can increase the risk for kidney stones, especially if the cheese is high in calcium or oxalates. Dairy products, including cheese, contain calcium, and excessive consumption can contribute to the formation of calcium oxalate stones, which are the most common type of kidney stones.

Choice C reason: Experiencing additional stress since adopting a child is not directly related to the formation of kidney stones. Stress can have various health impacts, but it is not a known primary risk factor for renal calculi.

Choice D reason: Jogging more frequently than the usual daily routine is not associated with an increased risk of kidney stones. Regular physical activity is generally beneficial for overall health and does not contribute to the formation of renal calculi.

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A female college student comes to the school's health clinic reporting urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

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