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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A reason: Sloughing tissue around wound edges may require debridement but does not typically require immediate intervention unless there is a significant change in the wound's condition.
Choice B reason: Loss of sensation could indicate nerve damage or developing compartment syndrome, which is a medical emergency requiring immediate intervention to prevent permanent damage.
Choice C reason: Weeping serosanguineous fluid is expected in burn wounds and does not necessarily require immediate intervention unless there is a significant increase in output or other signs of infection.
Choice D reason: Increased pain and pressure are signs of potential compartment syndrome or infection, both of which require prompt assessment and possible intervention.
Choice E reason: A change in the quality of peripheral pulses may indicate vascular compromise, which requires immediate intervention to restore circulation and prevent tissue death.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Choice A reason: No understanding.
While lifestyle changes can significantly reduce the risk of developing type 2 diabetes, they do not guarantee prevention. The client’s family history and current prediabetic fasting blood glucose level (122 mg/dL) indicate an increased risk. It’s important to understand that while risk can be minimized, it cannot be completely eliminated12.
Choice B reason:
People with diabetes or prediabetes can still consume sugar, but it should be in moderation and as part of a balanced diet. The DASH diet discussed with the client emphasizes portion control and a reduction in sugar intake, not complete elimination.
Choice C reason: No understanding
A single fasting blood glucose measurement below 100 mg/dL does not mean the client can revert to previous eating habits. Ongoing maintenance of a healthy diet and lifestyle is necessary to manage blood glucose levels and reduce the risk of diabetes.
Choice D reason: Understanding.
Lifestyle changes such as adopting the DASH diet and increasing physical activity can help manage weight, improve cholesterol levels, and lower the risk of chronic conditions like hypertension, cardiovascular disease, and type 2 diabetes.
Choice E reason: Understanding.
Increased thirst and urination are symptoms of high blood sugar levels. If the client experiences these symptoms, it would be prudent to check blood glucose levels to manage and monitor for diabetes.
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