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 A

Explanation

acromegaly typically causes an enlargement of the hands and feet. The nurse can inquire if the patient has noticed any changes in shoe size, as this may indicate abnormal growth.

"Are you experiencing tremors or anxiety" is not directly related to acromegaly, and although anxiety can be associated with some medical conditions, it is not a typical symptom of acromegaly.

"Is there any family history of acromegaly?" is also a relevant question, as acromegaly can be caused by a genetic disorder. If the patient has a family history of the condition, this may increase their risk of developing it.

"Have you had a recent head injury?" is not specifically related to acromegaly, although head trauma can cause a variety of medical conditions.

Overall, option a. is the most relevant question to ask a patient with suspected acromegaly.

A. Assess the patient’s perception of what it means to have type 2 diabetes. B. Ask the patient’s family to participate in the diabetes education program. C. Demonstrate how to check glucose using capillary blood glucose monitoring. D. Discuss the need for the patient to actively participate in diabetes management.

Correct Answer is A

Explanation

The first step in the education plan should be to assess their understanding and perception of the disease. This will help the nurse to identify any misconceptions or knowledge gaps that the patient may have and tailor the education plan accordingly. Understanding the patient's perceptions will also help the nurse to establish a trusting relationship with the patient and increase their engagement in diabetes self-management.
Options b, c, and d are important components of the diabetes education plan, but they should be implemented after the initial assessment of the patient's perception and understanding of their diagnosis.

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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 patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask?

Correct Answer is A

Explanation

Mary, a 63-year-old patient is newly diagnosed with type 2 diabetes. When determining an education plan, the nurse’s first action should be to?

Correct Answer is A

Explanation

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