The nurse is caring for a hospitalized client who is attempting to pass a kidney stone. Which clinical manifestation should the nurse recognize as Indicating a potential emergency situation?
Renal colic
Hematuria in urinalysis
Nausea
Anuria
The Correct Answer is D
D. Anuria refers to the absence of urine production, which can occur due to urinary tract obstruction, severe dehydration, or renal failure. In the context of a client attempting to pass a kidney stone, anuria would be a concerning sign indicating potential urinary tract obstruction requiring urgent medical attention.
A. Renal colic refers to severe flank pain caused by the passage of a kidney stone through the urinary tract. While renal colic is a common symptom of kidney stones and can cause significant discomfort, it does not necessarily indicate an emergency situation unless it is associated with complications such as obstructive uropathy or infection.
B. Hematuria, or blood in the urine, is a common finding in individuals with kidney stones. It occurs due to irritation or injury to the urinary tract as the stone passes through.
C. Nausea is a common symptom experienced by individuals with kidney stones, particularly if there is associated pain or discomfort. While nausea can be distressing, it does not typically indicate an emergency situation unless it is severe and persistent, leading to dehydration or other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Teach the client to support the surgical site while deep breathing and coughing: This action is appropriate as it helps prevent complications such as atelectasis and pneumonia by promoting lung expansion and clearing secretions. Supporting the surgical site while deep breathing and coughing helps reduce pain and discomfort during these activities.
B. This is an important teaching point for clients using PCA for pain control after surgery. Opioid medications used in PCA can lead to gastrointestinal motility issues, including constipation. However, pain management is central within the first 24 hours post operation.
C. Irrigating and repositioning the NGT frequently can increase the risk of complications such as displacement or irritation of the surgical site. NGT care should be performed as needed based on institutional protocols and the client's condition.
D. The client's diet will likely be advanced gradually, starting with clear fluids and progressing to full liquids and then solid foods as tolerated. Fruit juices may be introduced gradually as part of the liquid diet once the client's gastrointestinal function has recovered sufficiently.
Correct Answer is D
Explanation
D. The initial clinical manifestation associated with an obstruction in the duodenum is crampy abdominal pain, wavelike, and colicky. This discomfort occurs due to the blockage of the small intestine, leading to spasms and pain as the body tries to move contents past the obstruction.
A. Severe abdominal distention and cramping can occur with various gastrointestinal conditions, including an obstruction in the duodenum. However, this manifestation is not specific to duodenal obstruction and can occur with obstructions at other locations in the gastrointestinal tract.
B. Vomiting of fecal material, known as feculent vomiting, is a hallmark sign of a complete obstruction in the lower gastrointestinal tract.
C. Ribbon-like stools are more commonly associated with conditions affecting the lower gastrointestinal tract, such as colorectal cancer or irritable bowel syndrome (IBS).
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