A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

Palpate the right flank for tenderness.

Test the urine for the presence of hematuria.

Evaluate the urine for a strong odor.

Measure the temperature and pulse rate.

Answer and Explanation

The Correct Answer is D

A. Palpating the right flank for tenderness is essential to assess for possible renal involvement, such as a kidney infection or kidney stone, which could be causing the urinary symptoms and right lower back pain. However, it is not the initial step.

B. Testing the urine for the presence of hematuria is important in assessing for potential urinary tract infection or other renal pathology but does not directly address the cause of the right lower back pain.

C. Evaluating the urine for a strong odor may provide information about a possible urinary tract infection, but it is not the most immediate intervention for addressing the client's symptoms, compared to measuring the vital signs.

D. Measuring the temperature and pulse rate is important for identifying any signs of systemic infection or inflammation that could be contributing to the patient's symptoms.

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

Explanation

In the provided scenario, the two key pieces of subjective data indicating the need for health interventions are the client's report of using a rescue inhaler multiple times without relief and the exacerbation of symptoms when outdoors and during exercise. These details suggest that the client's asthma is not well-controlled, and the ineffectiveness of the rescue medication, especially with an expired inhaler, warrants immediate medical attention.

A. Avoid wearing tight fitting clothes. B. Minimize intake of spicy foods. C. Begin a smoking cessation program. D. Remain upright following meals.

Correct Answer is D

Explanation

A. Avoiding tight-fitting clothes can help reduce intra-abdominal pressure, which may contribute to GERD symptoms, but it is not the most crucial instruction.

B. Minimizing intake of spicy foods can help decrease gastric irritation and reflux symptoms, but it is not the most important instruction.

C. Beginning a smoking cessation program is important for overall health and may help reduce GERD symptoms, but it is not the most critical instruction for managing GERD.

D. Remaining upright following meals is essential to prevent gastric reflux by reducing pressure on the lower esophageal sphincter. This instruction helps minimize reflux episodes and should be emphasized to the client with GERD.

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A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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Correct Answer is D

Explanation

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