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

Test her urine for the presence of haematuria.

Measure her temperature and heart rate.

Evaluate the urine for a strong Odor.

Palpate the right flank for tenderness.

Answer and Explanation

The Correct Answer is B

Choice A reason: Testing the urine for the presence of haematuria is important for diagnosing a urinary tract infection (UTI) or kidney stones, but it is not the most immediate intervention. Haematuria indicates blood in the urine, but assessing the client's vital signs is more urgent to determine if there is an acute issue that requires immediate attention.

Choice B reason: Measuring her temperature and heart rate is the most critical first step. These vital signs can provide immediate information about the client's overall condition and help identify potential systemic infection (fever) or hemodynamic instability (tachycardia). This information is essential for prioritizing further interventions and determining the urgency of the situation.

Choice C reason: Evaluating the urine for a strong Odor can help identify the presence of a UTI, but it is not as immediately critical as assessing the client's vital signs. Changes in urine Odor can support a diagnosis, but they do not provide the urgent information needed to assess the client's immediate health status.

Choice D reason: Palpating the right flank for tenderness is important for assessing kidney involvement, such as in cases of pyelonephritis (kidney infection). However, this physical examination should follow the assessment of vital signs to ensure the client is stable and not in immediate danger.

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Correct Answer is D

Explanation

Choice A reason: Serum potassium of 5.0 me/L and serum sodium of 138 me/L are within normal ranges and do not reflect the expected electrolyte imbalances due to dehydration from vomiting and diarrhea.

Choice B reason: Serum potassium of 4.5 me/L and serum sodium of 140 me/L are also within normal ranges. This does not reflect the typical imbalance caused by dehydration.

Choice C reason: Serum potassium of 3.5 me/L and serum sodium of 142 me/L are normal values. They do not indicate the electrolyte disturbances expected with dehydration from vomiting and diarrhea.

Choice D reason: Serum potassium of 3.0 me/L indicates hypokalaemia (low potassium), and serum sodium of 149 me/L indicates hypernatremia (high sodium). These imbalances are expected in a client with a history of fever, vomiting, and diarrhea, as these conditions can lead to loss of potassium and concentration of sodium due to dehydration.

A. Frequency of sexual activity. B. Environmental toxin exposure. C. Familial history of diabetes. D. Current medication regimen.

Correct Answer is D

Explanation

Choice A reason: Frequency of sexual activity can provide useful information about the client's sexual health and habits, but it is not the most critical information needed to address erectile dysfunction. The nurse needs to determine if there are any immediate factors contributing to ED, such as medication side effects.

Choice B reason: Environmental toxin exposure can have long-term health effects, including on sexual function. However, it is not the most urgent factor to consider when evaluating a client with erectile dysfunction. Immediate information about medications and medical history is more pertinent.

Choice C reason: Familial history of diabetes is important because diabetes can affect erectile function due to vascular and neurological complications. Yet, while this background information is useful, it is not the most immediate concern compared to potential medication side effects.

Choice D reason: The current medication regimen is the most important information for the nurse to obtain. Many medications can contribute to erectile dysfunction as a side effect. By identifying the medications the client is taking, the nurse can determine if ED might be a side effect and discuss possible adjustments or alternatives with the healthcare provider.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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