A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.).

Distended bladder.

Dysuria.

Report of feeling pressure.

Voiding 30 mL frequently.

Tenderness over the symphysis pubis.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale:
A distended bladder is a common sign of urinary retention, which can occur with prostatic hypertrophy. The enlarged prostate can block the flow of urine, causing the bladder to become distended.
Choice B rationale:
Dysuria, or painful urination, is not typically associated with urinary retention. It is more commonly seen in urinary tract infections.
Choice C rationale:
Feeling pressure is a common symptom of urinary retention. The pressure is caused by the buildup of urine in the bladder.
Choice D rationale:
Voiding small amounts frequently can be a sign of urinary retention. The bladder is not able to fully empty, so small amounts of urine are passed frequently.
Choice E rationale:
Tenderness over the symphysis pubis can be a sign of a distended bladder. The bladder is located just behind the symphysis pubis, so distention can cause tenderness in this area.

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Correct Answer is B

Explanation

Choice A rationale:
Turning the client’s head to the side is important to prevent aspiration, but it should be done after documenting the time the seizure began.
Choice B rationale:
The first action when a client begins having a tonic-clonic seizure is to document the time the seizure began. This helps in determining the duration of the seizure, which is critical information for the healthcare team.
Choice C rationale:
Loosening the clothing around the client’s waist is important for the client’s comfort and safety during a seizure, but it should be done after documenting the time the seizure began.
Choice D rationale:
Checking the client’s motor strength is not the first action to take when a client begins having a tonic-clonic seizure.

A. Pull the curtains around the client's bed. B. Ask family members to leave the room. C. Use sterile drapes to cover the client. D. Close the door to the client's room.

Correct Answer is A

Explanation

Choice A rationale:
Pulling the curtains around the client’s bed ensures privacy during the procedure.
Choice B rationale:
Asking family members to leave the room might be necessary, but it’s not the priority action.
Choice C rationale:
Using sterile drapes to cover the client is important for maintaining sterility, not privacy.
Choice D rationale:
Closing the door to the client’s room can provide privacy, but pulling the curtains around the bed is a more immediate action.

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A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who is undergoing a lumbar puncture. Which of the following is the priority action for the nurse to take to maintain privacy for the client?

Correct Answer is A

Explanation

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