The practical nurse (PN) notices that a client's urine is pale yellow, with a cloudy appearance, and has a foul odor. Which assessment should the PN complete next?
Assess skin appearance and elasticity.
Observe the feet and legs for swelling.
Ask the client about urinary frequency.
Palpate the bladder area for distention.
The Correct Answer is C
A. Assess skin appearance and elasticity: This assessment helps evaluate hydration status but does not directly relate to the foul-smelling, cloudy urine, which may indicate a urinary tract infection (UTI).
B. Observe the feet and legs for swelling: Peripheral edema is more related to fluid retention or kidney dysfunction, but the immediate concern with cloudy, foul-smelling urine is potential infection, not edema.
C. Ask the client about urinary frequency: Changes in urinary frequency, urgency, or discomfort are key symptoms of a UTI. Gathering this information helps identify the extent of the urinary problem and guides further intervention.
D. Palpate the bladder area for distention: Bladder palpation assesses retention, which is useful in some urinary issues, but it does not directly evaluate infection or correlate with foul-smelling, cloudy urine.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Check the pedal pulse in the affected leg: Assessing circulation is important when vascular compromise is suspected, but a leg cramp during labor is typically due to muscle spasm, not circulatory problems. The priority is relieving discomfort through positioning.
B. Massage the calf and foot: Massaging the calf is contraindicated until a circulatory issue, such as a deep vein thrombosis, is ruled out. Manipulating the area could dislodge a clot if one were present, posing a serious risk.
C. Elevate the leg above the heart: Elevating the leg may reduce swelling but will not relieve a muscle cramp caused by strain or poor positioning during labor. It does not directly address the muscle tension responsible for the pain.
D. Extend the leg and flex the foot: This action stretches the gastrocnemius muscle and relieves the spasm causing the cramp. It is the safest and most effective immediate intervention for muscle cramps in laboring clients.
Correct Answer is B
Explanation
A. Headache pain: While headache may occasionally occur, it is not the primary concern when assessing a client who has stopped taking divalproex sodium. The main focus should be on the client’s psychological and behavioral status, as relapse into mania or depression poses greater risk.
B. Frame of mind: Assessing the client’s frame of mind is the most important parameter, as discontinuation of divalproex sodium can lead to mood destabilization, including manic or depressive episodes. Evaluating current mood, thought content, and potential suicidal or risky behavior is essential to ensure safety and guide urgent interventions.
C. Hyperactivity: Hyperactivity is a common symptom of mania, but it represents only one behavioral manifestation. It should be assessed within the broader context of the client’s mood and affect, which provides a more complete picture of current stability or relapse.
D. Speech pattern: Rapid or pressured speech may indicate mania, yet it is a secondary assessment finding. The priority remains to evaluate the client’s overall frame of mind to determine the extent of mood disturbance and the need for psychiatric intervention.
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