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 D

Explanation

Choice A rationale:
Administering pain medication is important, but it’s not the first priority. The first priority is to stabilize the client’s condition.
Choice B rationale:
Administering a tetanus booster is necessary for burn patients, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice C rationale:
Cleaning and dressing the wound is important, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice D rationale:
Administering IV fluids is the first intervention for a burn patient. This is because burns can cause significant fluid loss, leading to dehydration and shock.

A. Turn the client's head to the side. B. Document the time the seizure began. C. Loosen the clothing around the client's waist. D. Check the client's motor strength.

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.

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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 in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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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.).