An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?
Obtain a urine specimen for culture and sensitivity.
Instruct in effective techniques to cleanse the glans penis.
Palpate the client's suprapubic area for distention.
Advise the client to maintain a voiding diary for one week.
The Correct Answer is C
Choice A reason: While obtaining a urine specimen is important for diagnosing infection, it does not address the immediate discomfort and potential urinary retention the client may be experiencing.
Choice B reason: Cleansing the glans penis is part of good hygiene but does not address the client's symptoms of a full bladder and weak urine flow.
Choice C reason: Palpating for suprapubic distention can provide immediate information about bladder fullness and potential urinary retention, which may require prompt intervention.
Choice D reason: Maintaining a voiding diary is useful for tracking symptoms over time but does not provide an immediate assessment or intervention for the client's current symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Elevated blood pressure is a concern but not as immediately threatening as some other symptoms associated with mitral valve stenosis.
Choice B reason: A rapid, irregular heart rate could indicate atrial fibrillation, which is common in mitral valve stenosis, but it is not as urgent as blood-tinged sputum.
Choice C reason: Swollen feet and ankles suggest fluid retention, which is a concern in mitral valve stenosis but not as immediate as hemoptysis.
Choice D reason: Blood-tinged sputum indicates hemoptysis, which can be a sign of pulmonary edema or other serious complications requiring immediate intervention. This symptom is the most urgent and could signify a potentially life-threatening condition.
Correct Answer is C
Explanation
Choice A reason: Mild sedation is a common and expected side effect of ramelteon, which is a sedative used to treat insomnia. It is generally not a cause for concern unless it persists or worsens.
Choice B reason: Dizziness reported after the initial dose is also a common side effect of ramelteon. It usually diminishes as the body adjusts to the medication. However, if dizziness persists or is severe, it should be reported to the healthcare provider.
Choice C reason: Somnambulism, or sleepwalking, is a serious side effect that should be reported to the healthcare provider immediately. Ramelteon can cause people to engage in activities while not fully awake and have no memory of the activity afterward. This could include walking, driving, eating, or making phone calls, and poses a significant safety risk.
Choice D reason: A change in the sleep-wake cycle is an expected effect of ramelteon, as it is used to manage the sleep-wake cycle in people with insomnia. It is not typically a side effect that needs to be reported unless the changes are extreme or cause significant distress.
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