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Patient Data

Exhibits

The nurse reviews the history and physical, the nurses' notes, and flow sheet to see what is causing the client's symptoms.

Click to highlight the findings that require follow-up.

A 70-year-old male visits his primary healthcare provider reporting an increase

in urinary urgency and frequency. The client reports that he has been waking 2 to 3 times at night needing to void. He reports that there have been 3 to 4 incidences of incontinence over the last 3 months, which has caused him to feel embarrassed. The client has a history of obesity and diabetes mellitus that is controlled with metformin 1,500 mg PO daily. Client reports a penile implant that was inserted 20 years ago and had no issues since then. Other medications include atorvastatin 20 mg PO daily for high cholesterol, a daily multivitamin, and 200 mg of ibuprofen PO 1 to 2 times a week for generalized aches and pains.

increase in urinary urgency and frequency

client reports that he has been waking 2 to 3 times at night needing to void.

He reports that there have been 3 to 4 incidences of incontinence over the last 3 months

200 mg of ibuprofen PO 1 to 2 times a week

a history of obesity and diabetes mellitus

Client reports a penile implant that was inserted 20 years ago and had no issues since then

atorvastatin 20 mg PO daily for high cholesterol

Answer and Explanation

The Correct Answer is ["A","B","C","D"]

Increased Urinary Urgency and Frequency and Nocturia: These symptoms warrant further investigation for possible underlying conditions such as BPH or other genitourinary issues.

Penile Implant: Changes in sexual function or discomfort with the penile implant should be evaluated to ensure there are no complications.

Ibuprofen Use: Assessment of the impact of ibuprofen on urinary symptoms and overall health should be considered.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. The urinary meatus is the external opening of the urethra and is not the source of the infection in this case.

B. The client's bed is not a direct reservoir for the infection, although poor hygiene practices can contribute to contamination.

C. Catheter tubing can harbor bacteria if not properly managed, leading to urinary tract infections. Prolonged periods without proper drainage can allow bacteria to multiply.

D. The client's bladder can become infected due to bacteria introduced via the catheter tubing, but it is not the initial reservoir.

A. Infuse normal saline intravenously. B. Apply external cooling blanket. C. Provide a bottle of electrolyte solution. D. Administer an antipyretic rectally.

Correct Answer is A

Explanation

A. Infusing normal saline intravenously is crucial as the infant shows signs of dehydration (weak cry, no tears), and intravenous fluids are necessary to restore hydration and electrolyte balance.

B. Applying an external cooling blanket may be necessary to manage fever but does not address the dehydration issue.

C. Providing an electrolyte solution is helpful, but given the infant’s refusal to drink, IV fluids are more immediate and effective.

D. Administering an antipyretic rectally might help manage fever but does not address the dehydration or fluid needs.

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Body System	Assessment Finding
Neurological	Restless Awake and alert Anxious
Respiratory	Respiratory rate 28 breaths/minute Oxygen Saturation 90% on room air Productive cough
Cardiovascular	Heart rate 101 beats/minute Capillary refill 4 seconds Blood pressure 145/89 mm Hg

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection. In evaluating the cause of the infection, what should the nurse identify as the infection reservoir?

Correct Answer is C

Explanation

A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which prescription is most important for the nurse to implement?

Correct Answer is A

Explanation

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care?

While conducting dietary teaching to the parent of an 11-month-old who was diagnosed with milk baby anemia, which food(s) should the nurse encourage the parent to offer the infant? Select all that apply.

A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.