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. Explain the tests to the wife so she can interpret them for her husband. B. Assess the client's ability to follow directions before proceeding with the exam. C. Defer this part of the exam because the results are likely to be invalid. D. Perform the tests because the client's mental status does not affect sensory status.

Correct Answer is B

Explanation

A. Explain the tests to the wife so she can interpret them for her husband: While involving family members can be helpful in some situations, it is essential for the client to actively participate in sensory assessments. Having the wife interpret the tests may not give an accurate representation of the client’s sensory capabilities.

B. Assess the client's ability to follow directions before proceeding with the exam: Accurate sensory testing relies on the client's ability to understand and follow instructions, as well as to accurately report sensations. It is important to first evaluate whether the client can understand and follow instructions, as cognitive or memory issues may affect their ability to engage in the sensory exam. This step ensures that the assessment results are valid and reflective of the client’s true sensory function.

C. Defer this part of the exam because the results are likely to be invalid: While cognitive decline can impact the reliability of the exam, it is essential to assess the client's ability to participate and follow instructions before determining whether the sensory exam can be conducted properly. Deferring the exam without evaluation of comprehension is inappropriate.

D. Perform the tests because the client's mental status does not affect sensory status: While mental status may not directly affect the sensory pathways, the ability to follow directions and focus on the exam does influence the accuracy of the assessment. Proceeding without assessing the client's ability to participate could result in inaccurate findings.

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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

While taking a history on an older adult male client, his wife reports that he is having increasing periods of short-term memory loss and he occasionally gets confused. How should the nurse proceed with an assessment of the client's sensory system?

Correct Answer is B

Explanation

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