An older adult male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?

Observe the scrotum for swelling.

Inspect the urethral meatus for discharge.

Question the client about related symptoms.

Palpate the inguinal area for a bulge.

Answer and Explanation

The Correct Answer is C

A. Observe the scrotum for swelling: Scrotal swelling might indicate issues such as a hydrocele, varicocele, or hernia, but it is not directly linked to urinary difficulties like nocturia or trouble initiating urination. It’s not the most targeted assessment in this context.

B. Inspect the urethral meatus for discharge: Discharge can suggest infection, such as urethritis or sexually transmitted infections, but it’s not a common finding in cases of nocturia and hesitancy typically associated with prostate issues.

C. Question the client about related symptoms: Asking about related symptoms such as weak stream, dribbling, incomplete emptying, or urgency helps the nurse assess for conditions like benign prostatic hyperplasia (BPH). This focused history provides critical insight into urinary function and guides further evaluation or referral.

D. Palpate the inguinal area for a bulge: This checks for inguinal hernias, which can cause groin discomfort but are not typically linked with urinary hesitancy or nocturia. It's a useful exam, but not the most relevant first step based on the symptoms presented.

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Correct Answer is A

Explanation

A. Review the client's medication list: Certain medications such as opioids, cholinergics, or miotic eye drops can cause pupillary constriction and sluggish reactivity. Reviewing the client’s medication profile can help determine if the abnormal pupillary response is pharmacologically induced or a sign of a neurological problem.

B. Assess the client's visual fields: Visual field testing evaluates peripheral vision and is not directly related to assessing pupillary response. This would not provide immediate insight into the cause of constricted pupils and is not the priority action in this situation.

C. Brighten the light in the client's room: While lighting can affect pupil size during assessment, constricted pupils with minimal response typically indicate an internal cause rather than poor lighting. Brightening the room may not significantly alter findings or explain the abnormal response.

D. Administer PRN saline eye solution: Saline eye drops may relieve dryness or irritation but have no effect on pupil size or reactivity. Administering them does not address the root cause of constricted pupils and could delay proper assessment and treatment.

A. Ask if the client took any pain medication at home. B. Use a standard pain assessment questionnaire and scale. C. Collect a urine sample and strain for granules or calculi. D. Observe for nonverbal signs to measure pain intensity.

Correct Answer is B

Explanation

A. Ask if the client took any pain medication at home: While this is important for evaluating pain management and potential medication interactions, it does not quantify the current pain level or guide immediate intervention. It should follow initial assessment.

B. Use a standard pain assessment questionnaire and scale: This is the priority initial intervention. A thorough and objective pain assessment helps the nurse determine the severity, location, and nature of the pain, which is critical for guiding further evaluation and management.

C. Collect a urine sample and strain for granules or calculi: Straining urine is important for diagnostic confirmation of kidney stones, but it is not the first action. Pain assessment should be completed first to guide symptom management and determine urgency.

D. Observe for nonverbal signs to measure pain intensity: Observing nonverbal cues is useful, especially if the client cannot verbalize their pain. However, since the client is alert and able to report symptoms, a structured pain scale provides more accurate and standardized data.

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An older adult male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After checking a client's pupillary response to light, the practical nurse (PN) tells the registered nurse (RN) that the client's pupils are constricted with minimal response to light. Before verifying the PN's findings, which action should the RN take?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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