An older 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?

Question the client about related symptoms.

Palpate the inguinal area for a bulge.

Inspect the urethral meatus for abnormalities.

Observe the scrotum for swelling.

Answer and Explanation

The Correct Answer is A

Choice A reason: Questioning about related symptoms (e.g., urgency, frequency) clarifies nocturia and hesitancy, suggesting causes like benign prostatic hyperplasia. This comprehensive data guides targeted assessments, ensuring accurate diagnosis and treatment, per urological assessment and patient history standards in elderly male nursing care.

Choice B reason: Palpating for an inguinal bulge assesses hernia, unrelated to nocturia or hesitancy. Questioning related symptoms better identifies urinary issues, guiding diagnosis. Hernias are not primary causes, per urological assessment and differential diagnosis protocols in nursing care for urinary complaints.

Choice C reason: Inspecting the meatus for abnormalities or discharge may follow but is less comprehensive than symptom questioning, which broadens the urinary history. Symptoms like hesitancy suggest internal issues, per urological assessment and benign prostatic hyperplasia diagnostic standards in nursing practice for elderly men.

Choice D reason: Observing scrotal swelling assesses testicular issues, not directly linked to nocturia or hesitancy. Questioning symptoms like weak stream or dribbling prioritizes urinary tract evaluation, per urological and geriatric assessment protocols in nursing care for male urinary symptoms.

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Correct Answer is D

Explanation

Choice A reason: Discontinuing the nasal cannula is inappropriate, as 94% SpO₂ indicates mild hypoxemia from pneumonia, requiring oxygen to support alveolar diffusion. The rash likely results from cannula pressure, not oxygen delivery. Padding addresses the rash without compromising respiratory support, ensuring continued therapy.

Choice B reason: Decreasing to 1 L/minute may worsen hypoxemia in pneumonia, where inflamed alveoli impair gas exchange (SpO₂ 94%). The rash is from mechanical irritation, not flow rate. Padding relieves pressure, maintaining oxygen delivery to improve saturation, making flow reduction counterproductive to respiratory needs.

Choice C reason: Applying lubricant reduces friction but not pressure causing the red macular rash from prolonged cannula contact. Lubricants risk aspiration. Padding alleviates pressure points, preventing skin breakdown while maintaining oxygen for pneumonia, addressing the rash’s mechanical cause more effectively than lubrication.

Choice D reason: Placing padding around the cannula tubing relieves pressure on the cheek, preventing skin breakdown from the red macular rash. This maintains oxygen at 3 L/minute, critical for pneumonia’s hypoxemia, where inflamed alveoli reduce oxygen diffusion. Padding ensures skin integrity and respiratory support, addressing both issues effectively.

A. Recently received an influenza immunization. B. Corticosteroid cream was applied to the eczema. C. A grandson and his new pet dog recently visited. D. An old friend with eczema came for a visit.

Correct Answer is C

Explanation

Choice A reason: Influenza immunization is unlikely to cause eczema flare-ups, as it targets systemic immunity, not skin allergens. A new dog’s dander is a common trigger, making pet exposure more relevant, per dermatological assessment and eczema management protocols in nursing care.

Choice B reason: Corticosteroid cream treats eczema, reducing flare-ups, not causing them. A new dog’s dander is a likely allergen triggering symptoms. Cream use is therapeutic, per dermatological treatment and eczema exacerbation assessment standards in nursing practice during home visits.

Choice C reason: A grandson’s new pet dog introduces allergens like dander, a common eczema trigger, explaining the recent flare-up. Identifying environmental exposures is critical for pinpointing causes, guiding avoidance strategies, per eczema management and dermatological assessment protocols in nursing care.

Choice D reason: A friend with eczema is unlikely to trigger flare-ups, as eczema is not contagious. A new dog’s dander is a more probable allergen. Social contact is less relevant, per dermatological assessment and eczema trigger identification standards in nursing practice.

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An older 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 obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen per nasal cannula at 3 L/minute, the nurse observes a red macular rash developing on the client’s right cheek. Which intervention should the nurse implement?

Correct Answer is D

Explanation

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

Correct Answer is C

Explanation

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