Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Auscultate an area six inches below the umbilicus.

Palpate the area above the pubic symphysis.

Measure the girth of the client's lower abdomen.

Observe the appearance of the client's urine.

Answer and Explanation

The Correct Answer is B

A. Auscultating below the umbilicus is not effective for assessing urinary retention.

B. Palpating the area above the pubic symphysis allows the nurse to assess for bladder distention, which is a direct indicator of urinary retention.

C. Measuring the girth of the lower abdomen can be useful but is less specific than palpation for assessing bladder fullness.

D. Observing the urine's appearance does not directly assess for urinary retention.

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Correct Answer is B

Explanation

A. Ear pain and fever are not characteristic symptoms of mononucleosis.

B. Mononucleosis is often associated with a positive Epstein-Barr virus (EBV) test and symptoms of malaise, fatigue, and lymphadenopathy.

C. Increased BUN and serum creatinine indicate kidney function issues, which are not typically associated with mononucleosis.

D. While elevated WBC and sedimentation rate can occur, they are nonspecific and can be seen in many conditions; they are not defining symptoms of mononucleosis.

A. Drink between 8 to 10 cups (1.9 to 2.4 liters) of fluids daily. B. Avoid foods high in refined sugars. C. Eliminate the bedtime snack if heartburn develops after eating. D. Increase the percentage of protein in the diet if anemia develops. E. Choose complex carbohydrates that are high in fiber content.

Correct Answer is ["A","B","E"]

Explanation

A. Drink between 8 to 10 cups (1.9 to 2.4 liters) of fluids daily: Staying well-hydrated is important for overall health and can help manage blood sugar levels. Adequate fluid intake also supports kidney function and helps flush excess glucose from the body.

B. Avoid foods high in refined sugars: Foods high in refined sugars can cause rapid spikes in blood glucose levels. Avoiding these foods helps maintain better blood sugar control and prevents hyperglycemia.

C. Eliminate the bedtime snack if heartburn develops after eating: While avoiding bedtime snacks may help with heartburn, it is essential to manage blood sugar levels effectively. A bedtime snack may be necessary for maintaining stable glucose levels overnight, and alternatives or adjustments should be considered.

D. Increase the percentage of protein in the diet if anemia develops: While protein is important, increasing it solely to address anemia may not be the best approach. Anemia requires a balanced diet with adequate iron and other nutrients. Specific dietary recommendations should be tailored based on comprehensive assessment and guidance from a healthcare provider.

E. Choose complex carbohydrates that are high in fiber content: Complex carbohydrates, especially those high in fiber, are digested more slowly and have a more gradual effect on blood sugar levels. Fiber helps with glucose control and provides sustained energy.

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Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Nursing Test Bank

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The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

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