An older male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?
Question the client about related symptoms.
Palpate the inguinal area for a bulge.
Inspect the urethral meatus for abnormalities.
Observe the scrotum for swelling.
The Correct Answer is A
Choice A reason: Questioning about related symptoms (e.g., urgency, frequency) clarifies nocturia and hesitancy, suggesting causes like benign prostatic hyperplasia. This comprehensive data guides targeted assessments, ensuring accurate diagnosis and treatment, per urological assessment and patient history standards in elderly male nursing care.
Choice B reason: Palpating for an inguinal bulge assesses hernia, unrelated to nocturia or hesitancy. Questioning related symptoms better identifies urinary issues, guiding diagnosis. Hernias are not primary causes, per urological assessment and differential diagnosis protocols in nursing care for urinary complaints.
Choice C reason: Inspecting the meatus for abnormalities or discharge may follow but is less comprehensive than symptom questioning, which broadens the urinary history. Symptoms like hesitancy suggest internal issues, per urological assessment and benign prostatic hyperplasia diagnostic standards in nursing practice for elderly men.
Choice D reason: Observing scrotal swelling assesses testicular issues, not directly linked to nocturia or hesitancy. Questioning symptoms like weak stream or dribbling prioritizes urinary tract evaluation, per urological and geriatric assessment protocols in nursing care for male urinary symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Influenza immunization is unlikely to cause eczema flare-ups, as it targets systemic immunity, not skin allergens. A new dog’s dander is a common trigger, making pet exposure more relevant, per dermatological assessment and eczema management protocols in nursing care.
Choice B reason: Corticosteroid cream treats eczema, reducing flare-ups, not causing them. A new dog’s dander is a likely allergen triggering symptoms. Cream use is therapeutic, per dermatological treatment and eczema exacerbation assessment standards in nursing practice during home visits.
Choice C reason: A grandson’s new pet dog introduces allergens like dander, a common eczema trigger, explaining the recent flare-up. Identifying environmental exposures is critical for pinpointing causes, guiding avoidance strategies, per eczema management and dermatological assessment protocols in nursing care.
Choice D reason: A friend with eczema is unlikely to trigger flare-ups, as eczema is not contagious. A new dog’s dander is a more probable allergen. Social contact is less relevant, per dermatological assessment and eczema trigger identification standards in nursing practice.
Correct Answer is B
Explanation
Choice A reason: A red blood cell count of 3.5 x 10⁶/µL indicates anemia from myelosuppression, reducing oxygen transport. RBCs do not fight infection, so this does not support “risk for infection.” Low WBCs impair immune defense, increasing infection susceptibility, making WBC count more relevant to the nursing problem in this context.
Choice B reason: A WBC count of 1,500/mm³ indicates severe leukopenia from myelosuppression, reducing neutrophil production. This impairs immune response, significantly raising infection risk, as pathogens overwhelm the body’s defenses. This lab value directly supports “risk for infection,” necessitating precautions like isolation or antibiotics to prevent opportunistic infections.
Choice C reason: Hematocrit of 33% reflects anemia in myelosuppression, lowering oxygen delivery. This causes fatigue but does not increase infection risk, as RBCs are not immune cells. WBCs, particularly neutrophils, are critical for infection defense, making low WBC count more relevant to the nursing problem than hematocrit.
Choice D reason: Hemoglobin of 10 g/dL indicates anemia, reducing oxygen-carrying capacity in myelosuppression. This does not directly increase infection risk, as hemoglobin is not involved in immunity. Low WBCs compromise pathogen defense, making WBC count the key value supporting “risk for infection” in this client’s care plan.
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