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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Free Nursing Study Resources

Correct Answer is D

Explanation

A) Compare the shape of each of the pupils bilaterally with normal room light:
Assessing the shape of the pupils with normal room light is not specifically related to assessing pupillary reaction to accommodation. This action may be more relevant for assessing pupillary symmetry and shape, but it does not directly evaluate accommodation.

B) Determine if dilation of the pupils occurs when the room is darkened:
This action assesses the pupillary response to changes in light (pupillary light reflex), not specifically accommodation. While it is an important assessment, it does not target accommodation specifically.

C) Note the speed of pupil constriction when a penlight is shined into the eye:
This action assesses the pupillary light reflex, which involves the constriction of the pupils in response to light. While it is related to pupillary function, it does not specifically evaluate accommodation.

D) Observe pupil size when focusing on a near object and then a far object:
This action directly assesses the pupillary reaction to accommodation. When focusing on a near object, the pupils should constrict (miosis), and when focusing on a far object, the pupils should dilate (mydriasis). This response indicates that the pupils are adapting to changes in focal distance, demonstrating accommodation.

A. Elevate the head of the client's bed immediately. B. Use the bell of the stethoscope to auscultate again. C. Document the presence of borborygmi. D. Auscultate the remaining two quadrants. E. None F. None

Correct Answer is C

Explanation

Answer: C. Document the presence of borborygmi.

Rationale:

A. Elevate the head of the client's bed immediately:
While elevating the head of the bed may be appropriate in certain situations, it is not the necessary immediate action in this context. The presence of loud, high-pitched bowel sounds does not indicate a need for repositioning the client. Instead, the nurse should first focus on assessing the findings before making any positional changes.

B. Use the bell of the stethoscope to auscultate again:
The bell of the stethoscope is typically used for lower frequency sounds, such as heart murmurs or certain vascular sounds. Since the nurse has already identified high-pitched bowel sounds using the diaphragm, switching to the bell is not appropriate for this situation. The diaphragm is better suited for detecting the types of sounds the nurse is hearing.

C. Document the presence of borborygmi:
Borborygmi refers to the loud, gurgling bowel sounds that can indicate increased intestinal activity. Documenting this finding is essential as it provides a clear record of the client's bowel sounds at this moment. This documentation can aid in monitoring the client's gastrointestinal function and is crucial for continuity of care.

D. Auscultate the remaining two quadrants:
While it is important to auscultate all quadrants to get a complete assessment of bowel sounds, the immediate action after hearing significant sounds in two quadrants is to document the findings. Continuing the assessment can follow, but the documentation serves as an important step in patient care and communication among the healthcare team.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To assess a client's pupillary reaction to accommodation, which action should the nurse take?

Correct Answer is D

Explanation

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. Which action should the nurse implement?

Correct Answer is C

Explanation

Rationale:

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