The nurse is examining the abdomen of an older male client who expresses suprapubic tenderness on palpation. The client states that it sometimes feels like there is still pressure in that area after urination. Which additional finding should the nurse expect with continued interview of the client?
Black tarry stools.
A cloudy discharge.
An overactive bladder
A weak urinary stream.
The Correct Answer is D
Choice A Reason:
Black tarry stools are inappropriate. Black tarry stools may indicate gastrointestinal bleeding, which is not directly related to the client's symptoms of suprapubic tenderness and pressure after urination. While it's important to consider other potential health issues, such as gastrointestinal bleeding, it may not be directly relevant to the client's current urinary symptoms.
Choice B Reason:
A cloudy discharge is inappropriate. A cloudy discharge may suggest an infection or inflammation in the urinary tract, but it is not specifically associated with the symptoms described by the client (suprapubic tenderness and pressure after urination). While urinary tract infections (UTIs) can occur in older adults, they may present with symptoms such as urinary urgency, frequency, dysuria, and hematuria, rather than suprapubic tenderness and pressure after urination.
Choice C Reason:
An overactive bladder is inappropriate. While overactive bladder can cause urinary urgency and frequency, it is less likely to present with suprapubic tenderness and pressure after urination. Overactive bladder is characterized by sudden, involuntary contractions of the bladder muscles, leading to a frequent and urgent need to urinate. It may not directly explain the client's symptoms of suprapubic tenderness and pressure after urination, which are more suggestive of urinary obstruction due to BPH.
Choice D Reason:
A weak urinary stream is appropriate. Benign prostatic hyperplasia (BPH) is a common condition in older men characterized by noncancerous enlargement of the prostate gland, which can lead to compression of the urethra and urinary symptoms. A weak urinary stream is a classic symptom of BPH due to the obstruction caused by the enlarged prostate gland, which interferes with the normal flow of urine. Therefore, the nurse should expect a weak urinary stream as an additional finding during the client interview, which is consistent with the suspected diagnosis of BPH.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","F"]
Explanation
Choice A Reason:
Macule is incorrect. A macule is a flat, discolored spot on the skin that is less than 1 centimeter in diameter. It does not contain fluid; instead, it represents a change in the color of the skin, such as a freckle or a flat mole. Macules are not filled with fluid; they are characterized by alterations in skin pigmentation without any elevation or depression.
Choice B Reason:
Papule is incorrect. A papule is a small, raised bump on the skin that is less than 1 centimeter in diameter. Papules do not contain fluid; instead, they result from localized cellular infiltration, inflammation, or proliferation in the skin layers. Examples of papules include acne lesions and insect bites.
Choice C Reason:
While often confused with fluid-filled sacs, a wheal is an area of localized dermal edema. They are solid, itchy, and irregularly shaped (e.g., hives or insect bites).
Choice D Reason:
Vesicle is correct. A vesicle is a small, fluid-filled blister that appears on the skin. It contains clear fluid and can be caused by various factors such as infection, allergic reactions, or friction.
Choice E Reason:
Nodule is incorrect. A nodule is a solid, raised bump on the skin that is larger than 1 centimeter in diameter and extends into deeper layers of the skin. Similar to papules, nodules do not contain fluid; they are composed of tissue, such as fat, fibrous tissue, or tumors. Examples of nodules include lipomas and dermatofibromas.
Choice F Reason:
Pustule is correct. A pustule is a small, pus-filled blister that appears on the skin. It contains purulent fluid (pus) and is often associated with bacterial infections such as acne or folliculitis.
Correct Answer is A
Explanation
Choice A Reason:
Shrug shoulders against resistance is correct because cranial nerve XI, also known as the spinal accessory nerve, innervates the trapezius and sternocleidomastoid muscles. Instructing the client to shrug their shoulders against resistance tests the strength and function of the trapezius muscle, which is primarily innervated by cranial nerve XI. Therefore, this instruction directly assesses the function of the cranial nerve XI.
Choice B Reason:
Stand up slowly with eyes closed is incorrect because standing up slowly with eyes closed primarily assesses proprioception and balance, which involve multiple cranial nerves and the vestibular system. While cranial nerve XI may play a role in maintaining posture and balance, it is not the primary nerve involved in this assessment.
Choice C Reason:
Turn head from side to side is incorrect because turning the head from side to side primarily assesses the function of the sternocleidomastoid muscle, which is also innervated by cranial nerve XI. However, this action alone does not provide resistance against which the muscle can contract, making it less specific for assessing cranial nerve XI compared to the instruction to shrug the shoulders against resistance.
Choice D Reason:
Raise both arms overhead incorrect because raising both arms overhead primarily assesses motor function and strength of the upper extremities, which do not directly involve the muscles innervated by cranial nerve XI. While the trapezius muscle may be indirectly involved in shoulder movement, this action does not specifically target the function of cranial nerve XI.
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