The nurse is conducting a history on a male client to determine the severity of symptoms associated with prostate enlargement. Which finding is cause for prompt action by the nurse?
Hematuria
Weak Urinary System
Postvoid dribbling.
Urinary hesitancy
The Correct Answer is A
A. Hematuria: Blood in the urine may indicate serious complications such as infection, kidney damage, or possible malignancy. Prompt evaluation is required to rule out life-threatening conditions.
B. Weak urinary stream: This is a common symptom of benign prostatic hyperplasia (BPH) and generally does not require immediate intervention, though it should be monitored.
C. Postvoid dribbling: Dribbling after urination is a typical sign of prostate enlargement and usually indicates incomplete bladder emptying. It requires monitoring but is not an emergency.
D. Urinary hesitancy: Difficulty initiating urination is a common symptom of BPH. It can affect quality of life but typically does not require urgent action unless accompanied by acute urinary retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Give the client a nonenteric coated aspirin: Administering aspirin is important to reduce platelet aggregation in acute MI, but it should follow immediate assessment and ECG confirmation. It is part of initial management, not the first step for optimal outcomes.
B. Notify the Rapid Response Team immediately: While escalation is important for deteriorating patients, a client presenting with chest pain suggestive of MI should be prioritized for diagnostic confirmation and timely interventions.
C. Obtain an electrocardiogram (ECG) within 20 minutes: Rapid ECG acquisition is critical for confirming the diagnosis of acute MI and guiding urgent interventions. Achieving this within 20 minutes is a key quality measure associated with improved outcomes, making it the priority action.
D. Prepare to administer thrombolytics within 60 minutes: Thrombolytic therapy is indicated for certain types of MI (STEMI) but should be initiated after diagnostic confirmation via ECG. Preparing for administration is important but follows timely assessment.
Correct Answer is D
Explanation
A. Have the respiratory therapist provide humidified room air: Humidified air can help soothe airway irritation, but it does not address the immediate risk of airway compromise from potential inhalation injury. It is supportive but not the highest priority.
B. Allow the client to suck on small quantities of ice chips: Providing ice chips may help with oral dryness but does nothing to secure the airway or ensure adequate oxygenation. This intervention is low priority in the context of a brassy cough indicating possible airway injury.
C. Request an antitussive medication from the physician: Suppressing a cough could worsen airway clearance in a client with inhalation injury and does not prevent hypoxia or airway obstruction. This intervention could be harmful if applied prematurely.
D. Apply oxygen and continuous pulse oximetry: A loud, brassy cough after a fire suggests upper airway edema and possible inhalation injury, which can rapidly progress to airway obstruction. Ensuring adequate oxygenation and continuous monitoring is the priority to prevent hypoxia and respiratory compromise.
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