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?

Send the sample for laboratory evaluation.

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.

Answer and Explanation

The Correct Answer is C

Choice A Reason:
Sending the sample for laboratory evaluation is incorrect. Sending the urine sample for laboratory evaluation is a standard procedure to assess for any abnormalities, such as urinary tract infections (UTIs), kidney function, or other urinary tract disorders. While laboratory evaluation of the urine sample is important for diagnostic purposes, the client's difficulty providing an adequate urine sample suggests an underlying issue that needs to be addressed before obtaining a sample.
Choice B Reason:
Giving the client 8 ounces (236.5 mL) of water to drink is incorrect. Offering the client water to drink is a common intervention to encourage urine production and facilitate urine sample collection, particularly if the client is dehydrated or has difficulty producing a sample. However, given the client's symptoms of lower abdominal discomfort, frequent urination, and difficulty providing a urine sample despite efforts, simply offering water may not adequately address the underlying issue of potential bladder distention.
Choice C Reason:
Evaluating the client for bladder distention is correct. The client's symptoms of lower abdominal discomfort, frequent urination, and difficulty providing a urine sample after an extended period of time, along with returning with only a few drops of urine, are suggestive of potential bladder distention. Evaluating the client for bladder distention involves assessing for signs such as a visibly enlarged and palpable bladder, suprapubic discomfort or pain, and percussion of the bladder to assess for dullness, indicating fluid accumulation. Addressing bladder distention is essential to ensure the client's comfort and prevent complications associated with urinary retention.
Choice D Reason:
Instructing the client to attempt to urinate again is incorrect. Instructing the client to attempt to urinate again may be a reasonable intervention if the bladder is not distended and the client is simply having difficulty producing a urine sample. However, given the client's symptoms and the difficulty providing an adequate urine sample despite previous attempts, simply instructing the client to try again may not address the underlying issue of potential bladder distention. Evaluating for bladder distention is necessary to determine the appropriate course of action and ensure the client's comfort and safety.

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Correct Answer is B

Explanation

Choice A Reason:
Observing chest and upper neck for a rash is correct. This assessment is unrelated to tinnitus. Observing the chest and upper neck for a rash may be relevant in the context of other conditions, such as skin disorders or infectious diseases, but it does not provide information about the effects of tinnitus.
Choice B Reason:
Performing a hearing test is correct. Tinnitus is the perception of noise or ringing in the ears when no external sound is present. It can affect a person's hearing and overall quality of life. Therefore, the most appropriate assessment to evaluate the effects of tinnitus is to perform a hearing test. This test can assess the client's auditory function, including their ability to hear different frequencies and intensities of sound. By conducting a hearing test, the nurse can gather objective data on the client's hearing abilities and determine the extent to which tinnitus may be impacting their hearing sensitivity and perception.
Choice C Reason:
Evaluating for a loss of peripheral vision is incorrect. Loss of peripheral vision is not a typical effect of tinnitus. While tinnitus can affect auditory perception, it does not directly impact visual function, particularly peripheral vision. Therefore, evaluating for loss of peripheral vision is not relevant to assessing the effects of tinnitus.
Choice D Reason:
Assessing deep tendon reflexes is incorrect. Assessing deep tendon reflexes is unrelated to evaluating the effects of tinnitus. Deep tendon reflexes are assessed to evaluate the integrity of the neurological system and are typically tested in the context of assessing motor function and nerve responses. This assessment does not provide information about the auditory effects of tinnitus.

A. Epigastric region. B. Hypogastric region. C. Hypochondriac region. D. Umbilical region.

Correct Answer is A

Explanation

Choice A Reason:
Epigastric region is correct. The epigastric region is the area of the abdomen located between the lower part of the ribcage and the navel (umbilicus). Pain localized in the middle section of the abdomen below the xiphoid process corresponds to the epigastric region. This region encompasses the upper part of the stomach and the lower part of the esophagus, making it a common location for discomfort related to conditions such as gastritis, peptic ulcer disease, or gastroesophageal reflux disease (GERD).
Choice B Reason:
Hypogastric region is incorrect. The hypogastric region is located in the lower part of the abdomen, below the umbilical region. Pain in the hypogastric region typically corresponds to the lower abdomen, around the pubic bone, and may be associated with conditions such as bladder infections, menstrual cramps, or pelvic inflammatory disease.
Choice C Reason:
Hypochondriac region is incorrect. The hypochondriac regions are located on each side of the upper abdomen, beneath the ribs. Pain in the hypochondriac region may be associated with conditions affecting the liver, gallbladder, or spleen, but it does not correspond to the description provided by the client.
Choice D Reason:
Umbilical region is incorrect. The umbilical region is located around the navel (umbilicus) in the center of the abdomen. Pain in the umbilical region may be associated with conditions affecting the small intestine or structures around the navel, such as umbilical hernias. However, it does not specifically correspond to the description of pain below the xiphoid process in the middle section of the abdomen.

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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

In reading a client's record, the nurse notes that the client is experiencing tinnitus. Which assessment provides the nurse with the information needed to evaluate the effects of this condition?

Correct Answer is B

Explanation

A client reports experiencing stomach pain and it is localized in the middle section of the abdomen below the xiphoid process. The nurse should describe the pain as occurring in which region of the abdomen?

Correct Answer is A

Explanation

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