An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

Send the sample for laboratory evaluation.

Give the client 8 ounces (236.5 mL) of water to drink.

Evaluate the client for bladder distention.

Instruct the client to attempt to urinate again.

Answer and Explanation

The Correct Answer is C

Choice A Reason:
Sending the sample for laboratory evaluation is incorrect. Sending the urine sample for laboratory evaluation is a standard procedure to assess for any abnormalities, such as urinary tract infections (UTIs), kidney function, or other urinary tract disorders. While laboratory evaluation of the urine sample is important for diagnostic purposes, the client's difficulty providing an adequate urine sample suggests an underlying issue that needs to be addressed before obtaining a sample.
Choice B Reason:
Giving the client 8 ounces (236.5 mL) of water to drink is incorrect. Offering the client water to drink is a common intervention to encourage urine production and facilitate urine sample collection, particularly if the client is dehydrated or has difficulty producing a sample. However, given the client's symptoms of lower abdominal discomfort, frequent urination, and difficulty providing a urine sample despite efforts, simply offering water may not adequately address the underlying issue of potential bladder distention.
Choice C Reason:
Evaluating the client for bladder distention is correct. The client's symptoms of lower abdominal discomfort, frequent urination, and difficulty providing a urine sample after an extended period of time, along with returning with only a few drops of urine, are suggestive of potential bladder distention. Evaluating the client for bladder distention involves assessing for signs such as a visibly enlarged and palpable bladder, suprapubic discomfort or pain, and percussion of the bladder to assess for dullness, indicating fluid accumulation. Addressing bladder distention is essential to ensure the client's comfort and prevent complications associated with urinary retention.
Choice D Reason:
Instructing the client to attempt to urinate again is incorrect. Instructing the client to attempt to urinate again may be a reasonable intervention if the bladder is not distended and the client is simply having difficulty producing a urine sample. However, given the client's symptoms and the difficulty providing an adequate urine sample despite previous attempts, simply instructing the client to try again may not address the underlying issue of potential bladder distention. Evaluating for bladder distention is necessary to determine the appropriate course of action and ensure the client's comfort and safety.

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Correct Answer is ["C","D","E"]

Explanation

C. Chronic obstructive pulmonary disease (COPD): COPD is a chronic respiratory condition characterized by airflow limitation, typically caused by chronic bronchitis and/or emphysema. In COPD, the airways become narrowed and inflamed, leading to difficulty breathing. Over time, chronic hypoxia (low oxygen levels in the blood) can develop due to impaired gas exchange in the lungs. Chronic hypoxia can trigger compensatory mechanisms in the body, including vascular changes that result in clubbing of the nails. Therefore, clubbed nails can often be seen in individuals with COPD as a consequence of chronic tissue hypoxia.

D. Lung cancer: Lung cancer is a malignant tumor that arises from the cells of the lungs. It is often associated with long-term smoking, as in the case of this client. Lung cancer can impair lung function and compromise gas exchange, leading to chronic hypoxia. As with COPD, chronic hypoxia can induce vascular changes that result in clubbing of the nails. Therefore, clubbed nails can be a manifestation of advanced lung cancer, particularly in cases where chronic hypoxia is present due to impaired lung function.

E. Chronic bronchitis: Chronic bronchitis is a type of chronic obstructive pulmonary disease (COPD) characterized by inflammation and narrowing of the airways, leading to excessive mucus production and persistent cough. Similar to other forms of COPD, chronic bronchitis can result in chronic hypoxia due to impaired gas exchange in the lungs. The chronic hypoxia associated with chronic bronchitis can lead to vascular changes that cause clubbing of the nails over time. Therefore, individuals with chronic bronchitis may also exhibit clubbed nails as a consequence of chronic tissue hypoxia.

A. Normal mental status for age. B. Impaired concentration. C. Impaired memory. D. Impaired thinking.

Correct Answer is D

Explanation

Choice A Reason:
Normal mental status for age is incorrect. This choice would not be the most accurate conclusion based on the client's response. While it's possible that the client's response could be influenced by factors such as cultural background or personal interpretation, the inability to understand the metaphorical meaning of a commonly known proverb might suggest some level of cognitive impairment or difficulty with abstract thinking. Therefore, it would be premature to conclude that the client's response reflects a normal mental status for her age.
Choice B Reason:
Impaired concentration is incorrect. Impaired concentration would manifest as difficulty maintaining focus our attention during the interaction. However, the client's response doesn't suggest a lack of attention or focus. Instead, it indicates a misinterpretation of the proverb, which is more indicative of impaired thinking or difficulty understanding abstract concepts rather than impaired concentration.
Choice C Reason:
Impaired memory is incorrect. Impaired memory would typically involve difficulty recalling information or events from the past. In this scenario, the client is able to recall the phrase "Glass Houses" but demonstrates difficulty understanding its meaning. Therefore, impaired memory is not the most appropriate conclusion based on the client's response. Instead, the response suggests impaired thinking or difficulty with abstract reasoning.
Choice D Reason:
Impaired thinking is correct. The client's response indicates difficulty understanding the metaphorical meaning of the proverb "Glass Houses," which typically implies that those who live in fragile or vulnerable situations should avoid criticizing others, as they themselves are also vulnerable to criticism or judgment. Instead, the client's response focuses on the literal interpretation of the phrase, suggesting impaired thinking or difficulty grasping abstract concepts.

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An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse reviews client data. Select the 3 possible conditions that could have the symptom of clubbed nails for this client.

Correct Answer is ["C","D","E"]

Explanation

The nurse asks a female client about the proverb "Glass Houses," and she replies, "It will break the windows." Which conclusion should be documented about this client's response?

Correct Answer is D

Explanation

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