An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

Give the client 8 ounces (236.5 mL) of water to drink.

Evaluate the client for bladder distention.

Instruct the client to attempt to urinate again.

Send the sample for laboratory evaluation.

Answer and Explanation

The Correct Answer is B

A. Give the client 8 ounces (236.5 mL) of water to drink:
While encouraging hydration is important for overall urinary function, providing water to drink may not immediately address the client's current situation of difficulty providing a urine sample. It's essential to first determine if bladder distention is contributing to the client's symptoms.

B. Evaluate the client for bladder distention:
Given the client's symptoms of lower abdominal discomfort and difficulty providing a urine sample despite feeling the urge to urinate, bladder distention should be assessed. Bladder distention could indicate urinary retention, which may require intervention to relieve the discomfort and prevent complications such as urinary tract infection or bladder rupture.

C. Instruct the client to attempt to urinate again:
While encouraging the client to attempt to urinate again may be appropriate, it's essential to first assess for bladder distention to determine if there is an underlying issue contributing to the client's difficulty in providing a urine sample.

D. Send the sample for laboratory evaluation:
Sending the urine sample for laboratory evaluation is important for diagnostic purposes, but in this case, it's more important to address the immediate concern of the client's difficulty in providing an adequate sample. Evaluating for bladder distention would help guide further assessment and management.

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Correct Answer is C

Explanation

A) Dimpled area above anus:
This finding may indicate a pilonidal cyst, which is an abnormality rather than a normal appearance of the anus.

B) Flap of tissue at sphincter:
A flap of tissue at the anal sphincter, also known as the anal valve, is a normal anatomical feature. It helps maintain continence and prevents leakage of stool.

C) Increased pigmentation and coarse skin:
Increased pigmentation and coarse skin may be typical findings in the perianal area due to factors such as friction, moisture, or aging. While not everyone will have this appearance, it is within the range of normal variations.

D) Hypotonic tone of the anal sphincter:
Hypotonic tone of the anal sphincter may suggest weakness or dysfunction of the anal sphincter, which is not considered a normal finding.

A. Encourage fluid intake. B. Measure urine output. C. Splint the affected joint. D. Increase intake of red meat.

Correct Answer is A

Explanation

A. Encourage fluid intake:
Encouraging fluid intake is the most appropriate action for the client experiencing gout, as it helps to promote the excretion of uric acid through urine. Increased fluid intake can help prevent the formation of urate crystals in the joints and reduce the severity and frequency of gout attacks. It is a fundamental aspect of managing gout and preventing future episodes.

B. Measure urine output:
While monitoring urine output is important for overall assessment, it is not specifically indicated in the management of acute gout attacks. Gout is primarily managed by addressing hyperuricemia and reducing inflammation in the affected joints, which is best achieved through hydration and pharmacological interventions.

C. Splint the affected joint:
Splinting the affected joint may provide some relief by immobilizing it and reducing movement, but it does not address the underlying cause of gout or promote the excretion of uric acid. Splinting is more commonly used in the management of injuries or conditions that require joint stabilization.

D. Increase intake of red meat:
Increasing intake of red meat is contraindicated in clients with gout because red meat contains high levels of purines, which can exacerbate hyperuricemia and increase the risk of gout attacks. Dietary modifications for gout typically involve reducing the consumption of foods high in purines, such as red meat, organ meats, and certain seafood.

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An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

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