An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

Obtain a urine specimen for culture and sensitivity.

Instruct in effective techniques to cleanse the glans penis.

Palpate the client's suprapubic area for distention.

Advise the client to maintain a voiding diary for one week.

Answer and Explanation

The Correct Answer is C

Choice A reason: While obtaining a urine specimen is important for diagnosing infection, it does not address the immediate discomfort and potential urinary retention the client may be experiencing.

Choice B reason: Cleansing the glans penis is part of good hygiene but does not address the client's symptoms of a full bladder and weak urine flow.

Choice C reason: Palpating for suprapubic distention can provide immediate information about bladder fullness and potential urinary retention, which may require prompt intervention.

Choice D reason: Maintaining a voiding diary is useful for tracking symptoms over time but does not provide an immediate assessment or intervention for the client's current symptoms.

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Correct Answer is C

Explanation

Choice A reason: Asking for specifics about the night nurse's behavior could reinforce negative perceptions and does not address the client's current emotional state.

Choice B reason: Promising to talk to the night nurse may validate the client's split perception without verifying the facts.

Choice C reason: Expressing happiness for the client's improvement and discharge focuses on positive aspects and avoids engaging in potentially manipulative behavior.

Choice D reason: Acknowledging a preference for certain nurses can reinforce the client's splitting behavior, which is unhelpful in managing borderline personality disorder.

A. Decreased bowel sounds. B. Increased respiratory rate. C. Increased abdominal girth. D. Decreased level of consciousness.

Correct Answer is C

Explanation

Choice A reason: Decreased bowel sounds may be associated with cirrhosis due to altered digestion but do not directly correlate with weight gain.

Choice B reason: An increased respiratory rate can be a sign of many conditions, including fluid overload, but it is not a specific indicator of weight gain due to fluid accumulation.

Choice C reason: Increased abdominal girth is a common sign of ascites, which is fluid accumulation in the abdomen often seen in cirrhosis, correlating with the reported weight gain.

Choice D reason: Decreased level of consciousness may indicate hepatic encephalopathy in cirrhosis patients but does not directly correlate with the weight gain described.

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An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

While conducting a physical assessment, a client with cirrhosis of the liver reports to the nurse having had a 5 lb (2.3 kg) weight gain within the last week. Which assessment finding correlates with the client's comment?

Correct Answer is C

Explanation

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