A 98-year-old patient with benign prostatic hyperplasia has a markedly distended bladder and is agitated and confused. All the following orders are received from the emergency department health care provider. Which order should the nurse act on first?

Schedule for IVP.

Draw blood for blood urea nitrogen (BUN) and creatinine.

Insert 16 French retention catheter.

Administer lorazepam (Ativan) 0.5 mg.

Answer and Explanation

The Correct Answer is C

The nurse should act on the order to insert a 16 French retention catheter first. The patient's markedly distended bladder and agitated and confused state suggest acute urinary retention, which can be relieved by inserting a catheter to drain the urine. This is a priority intervention as urinary retention can lead to serious complications such as bladder rupture, hydronephrosis, and renal failure. Once the catheter is inserted and the patient's bladder is drained, the healthcare provider can order further tests such as an IVP or blood tests to assess renal function. The order for lorazepam can be addressed after the catheter is inserted and the patient's urinary retention is addressed.

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Correct Answer is D

Explanation

Cushing syndrome is a hormonal disorder caused by prolonged exposure to high levels of cortisol hormone in the body. It can cause a variety of physical manifestations, including truncal obesity, thin arms, and legs, decreased axillary and pubic hair, hypertension, glucose intolerance, osteoporosis, and purple striae (stretch marks) on the abdomen.

Out of the options given, the nurse would expect to find purplish-red streaks on the abdomen as an additional manifestation of Cushing syndrome.

A. The client's stool is positive for occult blood. B. The client reports abdominal discomfort an hour after each meal. C. The client has had four ulcers in the last 5 years. D. The client's hemoglobin is 13 g/dL and hematocrit is 42%.

Correct Answer is B

Explanation

Abdominal discomfort an hour after a meal is a common symptom of a gastric ulcer because the stomach is where food is initially processed, and stomach acid is most concentrated. In contrast, duodenal ulcers typically cause pain 2-3 hours after meals, as food moves out of the stomach and into the duodenum, where it encounters duodenal acid.

A positive stool occult blood test is a non-specific finding that can be caused by many gastrointestinal conditions, including peptic ulcers. It does not indicate the location of the ulcer.

The number of ulcers the client has had in the past does not indicate the location of the current ulcer.

Normal hemoglobin and hematocrit levels do not provide information about the location of the ulcer.

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A 98-year-old patient with benign prostatic hyperplasia has a markedly distended bladder and is agitated and confused. All the following orders are received from the emergency department health care provider. Which order should the nurse act on first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing assessment of a patient with Cushing syndrome reveals that the patient has truncal obesity and thin and legs. An additional manifestation of Cushing syndrome that the nurse would expect to find is:

Correct Answer is D

Explanation

The nurse is caring for a client with diagnosis of peptic ulcer disease. Which assessment finding indicates to the nurse that the client most likely has an ulcer in the stomach rather than the duodenum?

Correct Answer is B

Explanation

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