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

Evaluate the urine for a strong odor.

Measure her temperature and pulse rate

Test her urine for the presence of hematuria.

Palpate the right flank for tenderness

Answer and Explanation

The Correct Answer is B

A. Evaluate the urine for a strong odor.
While evaluating urine for a strong odor can provide some information about a possible urinary tract infection (UTI), it is not the most immediate concern. The priority in this case is to assess for signs of systemic infection, and checking for a strong odor can be done later.

B. Measure her temperature and pulse rate.
This is the correct choice. Measuring temperature and pulse rate is a critical initial step to assess for signs of systemic infection. Fever and an elevated pulse rate can indicate that the infection may have spread beyond the bladder, possibly involving the kidneys.

C. Test her urine for the presence of hematuria.
Testing for hematuria (blood in the urine) is an important diagnostic step for a UTI, but it is not the first priority. Vital sign assessment takes precedence to determine the severity of the condition and the need for urgent intervention.

D. Palpate the right flank for tenderness.
Palpating the right flank for tenderness is a relevant physical assessment to check for kidney involvement, which is important in cases of suspected pyelonephritis. However, assessing vital signs is a more immediate and critical step to determine the severity of the condition.

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Correct Answer is C

Explanation

A. Facial puffiness and periorbital edema:
These are common signs of hypothyroidism but may not require immediate action unless accompanied by severe symptoms.

B. Cold and dry skin:
Cold and dry skin is a characteristic feature of hypothyroidism, but a further decline in the level of consciousness is a more urgent issue.

C. Further decline in the level of consciousness.
A decline in the level of consciousness is a critical sign that requires immediate attention, as it may indicate worsening hypothyroidism, myxedema coma, or other serious complications. Myxedema coma is a life-threatening condition associated with severe hypothyroidism, and it requires prompt medical intervention.

D. Hematocrit of 30% (0.30):
While anemia is a potential complication of hypothyroidism, a hematocrit of 30% alone may not be the most immediate concern compared to a decline in the level of consciousness.

A. Family members can help with regular foot exams. B. Heating pads are useful if on the lowest setting. C. Aching feet may be soaked in lukewarm water for one hour or more. D. Shoes should be worn outside the house, but it is fine to be barefoot inside.

Correct Answer is A

Explanation

A. Family members can help with regular foot exams:
This is the correct answer. Regular foot exams are essential for individuals with diabetes, especially those with peripheral neuropathy. Family members can assist in identifying any changes, cuts, or wounds on the feet that the client might not be able to perceive due to neuropathy.

B. Heating pads are useful if on the lowest setting:
The use of heating pads is generally not recommended for individuals with peripheral neuropathy. They may have reduced sensation, making it difficult to detect if the pad is too hot, leading to the risk of burns.

C. Aching feet may be soaked in lukewarm water for one hour or more:
Prolonged soaking of feet is not advisable, as it can lead to maceration of the skin and increase the risk of infection. A short, lukewarm foot soak is generally acceptable, but the duration should be limited.

D. Shoes should be worn outside the house, but it is fine to be barefoot inside:
Individuals with diabetes and peripheral neuropathy should wear protective footwear both inside and outside the house to prevent injuries and reduce the risk of complications.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has a history of hypothyroidism was initially admitted with lethargy and confusion Which additional finding warrants the most immediate action by the nurse?

Correct Answer is C

Explanation

The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral neuropathy. Which information should the nurse provide?

Correct Answer is A

Explanation

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