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.
Send the sample for laboratory evaluation.
Instruct the client to attempt to urinate again.
Evaluate the client for bladder distention.
The Correct Answer is D
Choice A rationale
Giving the client 8 ounces (236.5 mL) of water to drink may help in obtaining a urine sample, but it does not address the immediate concern of potential bladder distention.
Choice B rationale
Sending the sample for laboratory evaluation is not appropriate when the sample is insufficient. The nurse should first address the underlying issue of why the client could not provide an adequate sample.
Choice C rationale
Instructing the client to attempt to urinate again may not be effective if the client is experiencing bladder distention or another underlying issue preventing urination.
Choice D rationale
Evaluating the client for bladder distention is the most appropriate action. Bladder distention can cause lower abdominal discomfort and difficulty urinating. Assessing for distention can help determine if the client needs further intervention, such as catheterization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A BMI of 32 kg/m² is not considered an appropriate weight for height. According to the American Heart Association, a BMI between 18.5 and 24.9 kg/m² is considered normal weight. A BMI of 32 kg/m² falls into the obese category, which indicates excess body fat and potential health risks.
Choice B rationale
While a BMI of 32 kg/m² is classified as obese, it is not categorized as extreme obesity. Extreme obesity is typically defined as a BMI of 40 kg/m² or higher. Therefore, this choice is incorrect.
Choice C rationale
A BMI of 32 kg/m² does not indicate undernutrition or malnutrition. Undernutrition is associated with a BMI of less than 18.5 kg/m². This choice is incorrect as the BMI in question indicates obesity, not undernutrition.
Choice D rationale
A BMI of 32 kg/m² is classified as obese. Obesity is a serious threat to well-being as it increases the risk of various health conditions, including heart disease, diabetes, hypertension, and certain cancers. Therefore, this choice is correct.
Correct Answer is B
Explanation
Choice A rationale
Sorting a collection of socks may assess cognitive function and fine motor skills, but it does not directly evaluate the ability to perform activities of daily living (ADL) such as bathing, dressing, or feeding.
Choice B rationale
Opening a bar soap package is a practical task that requires fine motor skills and dexterity, which are essential for performing activities of daily living (ADL) such as bathing and grooming.
Choice C rationale
Telephoning a family member assesses communication skills and cognitive function but does not directly evaluate the ability to perform activities of daily living (ADL)3.
Choice D rationale
Reading a short paragraph assesses cognitive function and literacy skills but does not directly evaluate the ability to perform activities of daily living (ADL)3.
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