Exhibits

The nurse is planning care for the client.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition
Urinary Retention
The client's symptoms, including the urge to void, feeling "wet," and the bladder scan showing 600 mL of residual urine, suggest urinary retention. Urinary retention occurs when the bladder does not empty completely or at all, leading to a buildup of urine. This can happen postoperatively due to anesthesia effects, pain, or bladder dysfunction.
Actions to Take
• Request prescription for straight catheter

A straight catheter (intermittent catheterization) is used to drain the bladder and measure the amount of urine collected. It is often preferred over an indwelling catheter in cases of acute urinary retention where temporary relief and assessment of bladder function are needed.
•   Insert indwelling urinary catheter
An indwelling urinary catheter might be needed if urinary retention persists and is not relieved by other methods. It allows continuous drainage of urine and can be useful in managing acute or severe cases of urinary retention.
Parameters to Monitor
•   Amount of urine output
Monitoring urine output is crucial to evaluate how effectively the bladder is emptying after catheterization or other interventions. This helps in assessing whether the urinary retention is being resolved.
•   Residual urine
Checking residual urine with a bladder scanner can help determine how much urine remains in the bladder after voiding. Persistent high residual urine levels would indicate ongoing retention issues that need further intervention.

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Free Nursing Study Resources

Correct Answer is ["B","E"]

Explanation

A. Pneumonia is an acute infection that causes inflammation in the lungs. While it can lead to significant respiratory symptoms and changes, it is not typically associated with clubbed nails. Clubbing usually develops over a longer period and is more common in chronic conditions.
B. Clubbing of the nails is often associated with lung cancer, particularly with bronchogenic carcinoma. The exact mechanism is not entirely clear, but it may relate to the presence of a malignancy causing systemic changes or the release of growth factors that affect nail tissue.
C. The flu is a viral respiratory infection that is usually acute and self-limiting. Clubbed nails are not a common manifestation of influenza. Clubbing is more associated with chronic respiratory and systemic conditions rather than acute viral infections.
D. COPD, which includes emphysema and chronic bronchitis, is not commonly associated with clubbing.

E. Chronic bronchitis, a type of COPD characterized by persistent cough and sputum production, may lead to clubbed nails in some cases. The chronic hypoxemia and long-term inflammation can contribute to this nail change, although it is less commonly seen than with other conditions.

A. Plan to assess the client's cognition after returning to his room. B. Confirm that this is an effective technique to help with ambulation. C. Reorient the client to his present location and circumstances. D. Assist the client to a carpeted area where he can walk more easily.

Correct Answer is B

Explanation

A. While assessing cognition is important for understanding the client’s overall functioning, the immediate issue of "freezing" during ambulation is more related to motor symptoms rather than cognitive impairment. "Freezing" in Parkinson's disease is a common motor symptom where the client feels as if their feet are glued to the floor.
B. The technique of pretending to step over an imaginary object (like a crack) is known to be a helpful strategy for managing "freezing" in Parkinson's disease. This technique provides a cognitive cue that can help the client initiate movement and overcome the freezing episodes. Confirming that this is an effective technique acknowledges the client's strategy and supports their efforts to improve mobility.

C. Reorienting the client to their location and circumstances can be helpful in situations where confusion or disorientation is an issue. However, in the case of "freezing" during ambulation, this response does not directly address the motor symptoms associated with Parkinson's disease. The problem here is more about movement initiation rather than orientation.
D. Moving to a carpeted area might help with traction and reduce the risk of slipping, but it does not directly address the issue of "freezing" episodes. The freezing phenomenon in Parkinson's disease is related to motor control rather than the type of flooring. While providing a safer walking environment is beneficial, it doesn’t target the underlying motor symptoms as directly as addressing the client’s technique.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is ["B","E"]

Explanation

The nurse assists a client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?

Correct Answer is B

Explanation

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