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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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A Reason:
Observing pupil size when focusing on a near object and then a far object is correct. This choice is correct because it directly assesses the pupillary reaction to accommodation, which refers to the changes in pupil size that occur when the eyes shift focus between near and far objects. Observing the pupils while the client focuses on a near object and then a far object allows the nurse to assess how the pupils constrict (become smaller) or dilate (become larger) in response to changes in focus, providing valuable information about the client's accommodation reflex.
Choice B Reason:
Comparing the shape of each of the pupils bilaterally with normal room light is incorrect. While comparing the shape of each pupil bilaterally with normal room light is a valid assessment technique for evaluating pupillary size and symmetry, it does not specifically assess the pupillary reaction to accommodation. Therefore, this choice is not as directly relevant to assessing accommodation reflex as choice A.
Choice C Reason:
Noting the speed of pupil constriction when a penlight is shined into the eye is incorrect. This choice refers to assessing the pupillary light reflex, which involves observing the speed and extent of pupil constriction in response to a bright light stimulus. While this assessment is important for evaluating the pupillary response to light, it does not specifically assess accommodation, which involves changes in pupil size in response to changes in focus between near and far objects. Therefore, this choice is not directly relevant to assessing accommodation reflex.
Choice D Reason:
Determining if dilation of the pupils occurs when the room is darkened is incorrect. This choice involves assessing the pupillary response to changes in ambient light levels, which is known as the pupillary light reflex. While assessing pupil dilation in response to darkness is important for evaluating the pupillary response to changes in light, it does not specifically assess accommodation reflex. Therefore, this choice is not directly relevant to assessing accommodation reflex.

A. Hyperextension and palmar flexion. B. Plantar flexion. C. Forearm pronation. D. Forearm supination.

Correct Answer is A

Explanation

Choice A Reason:
Hyperextension and palmar flexion are correct. Hyperextension involves moving the wrist joint backward, testing its ability to extend beyond its neutral position. Palmar flexion involves moving the wrist joint forward, testing its ability to flex toward the palm. These movements collectively assess the range of motion of the wrist joint in both directions, which is essential for identifying any limitations or pain associated with certain movements. Since the client presents with right wrist pain and ecchymosis, assessing both hyperextension and palmar flexion can help determine if there's any injury or impairment affecting the wrist's mobility.
Choice B Reason:
Plantar flexion is incorrect. Plantar flexion refers to a movement of the foot and ankle, not the wrist. Therefore, instructing the client to perform plantar flexion would not assess the wrist's mobility and is not relevant to the presented scenario of right wrist pain with ecchymosis.
Choice C Reason:
Forearm pronation is incorrect. Forearm pronation involves rotating the forearm so that the palm faces downward. This movement primarily assesses the pronation and supination of the forearm, not the wrist's mobility. Since the client's symptoms are specific to the wrist, assessing forearm pronation would not directly evaluate the wrist's range of motion.
Choice D Reason:
Forearm supination is incorrect. Forearm supination involves rotating the forearm so that the palm faces upward. Similar to forearm pronation, this movement primarily assesses the forearm's mobility, not the wrist's mobility. Therefore, instructing the client to perform forearm supination would not be an appropriate method for assessing the wrist's range of motion in the context of right wrist pain with ecchymosis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To assess a client's pupillary reaction to accommodation, what action should the nurse take?

Correct Answer is A

Explanation

A client is seen in the emergent care clinic for right wrist pain with a pattern of ecchymosis observed on the wrist. Which motion should the nurse instruct the client to perform to assess the wrist mobility?

Correct Answer is A

Explanation

The nurse is assessing a client with gallstones for jaundice. Which action should the nurse perform to confirm this information?

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