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

Auscultate an area six inches below the umbilicus.

Observe the appearance of the patient’s urine.

Palpate the area above the pubic symphysis.

Measure the girth of the patient’s lower abdomen.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.

Choice B rationale

Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.

Choice C rationale

Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.

Choice D rationale

Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.

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Correct Answer is A

Explanation

Choice A rationale

Changing the surgical dressing promptly when it becomes soiled is crucial to minimize the risk of a MRSA recurrence in the postoperative wound. A soiled dressing can become a medium for bacterial growth, including MRSA, and can potentially contaminate the wound.

Choice B rationale

Monitoring for any increase in the white blood cell count is important in detecting an infection, including a MRSA infection. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.

Choice C rationale

Educating the family on the importance of adhering to contact precautions is important in preventing the spread of MRSA. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.

Choice D rationale

Wearing a face mask while performing wound care can help prevent the spread of MRSA. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.

A. Phobia. B. Acute stress disorder related to traumatic stress exposure. C. Hallucinations. D. Separation anxiety.

Correct Answer is B

Explanation

Choice A rationale

Phobia is characterized by an excessive and irrational fear response. In this case, the patient’s symptoms do not indicate a specific fear, but rather general distress and intrusive thoughts related to a traumatic event.

Choice B rationale

The patient’s symptoms, which include distressing thoughts and memories of the house collapsing, difficulty sleeping, and a significant change in mood, are indicative of acute stress disorder related to traumatic stress exposure. Acute stress disorder can occur within a month of experiencing a traumatic event, like a natural disaster.

Choice C rationale

Hallucinations involve perceiving something that is not present. The patient’s symptoms do not include any indications of hallucinations.

Choice D rationale

Separation anxiety involves excessive fear or anxiety about separation from those to whom the individual is attached. The patient’s symptoms do not indicate a fear of separation, but rather distress related to a traumatic event.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is B

Explanation

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