The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Audible thud without pain.

Rigidity and firmness.

Rebound tenderness.

Sharp, severe pain.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Audible thud without pain is incorrect. An audible thud without pain would not be an expected response when percussing the costovertebral angle (CVA) in a client with pyelonephritis. Pyelonephritis typically presents with tenderness upon percussion of the CVA due to inflammation or infection of the kidneys. The absence of pain in this scenario would not be consistent with the expected response.
Choice B Reason:
Rigidity and firmness are incorrect. Rigidity and firmness upon percussion of the costovertebral angle (CVA) may suggest muscle tension or guarding, rather than the tenderness typically associated with kidney inflammation or infection such as pyelonephritis. While guarding can occur in response to pain, it is not the expected response when assessing for kidney tenderness.
Choice C Reason:
Rebound tenderness is incorrect. Rebound tenderness refers to the exacerbation of pain upon release of pressure, typically observed in conditions such as peritonitis. While rebound tenderness may be present in some abdominal conditions, it is not the expected response when percussing the costovertebral angle (CVA) to assess for kidney tenderness in pyelonephritis. In pyelonephritis, tenderness upon initial percussion is more indicative of the condition.
Choice D Reason:
Sharp, severe pain is correct. Sharp, severe pain upon percussing the CVA suggests tenderness, which can be indicative of kidney inflammation or infection, such as pyelonephritis. This finding would support the diagnosis and help guide further assessment and treatment.

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Correct Answer is A

Explanation

Choice A Reason:
Requesting diagnostic laboratory testing for the client is appropriate action. Enlargement of the thyroid gland can be indicative of various thyroid disorders, including hyperthyroidism, hypothyroidism, or thyroid nodules. Diagnostic laboratory testing, such as thyroid function tests (TFTs), thyroid antibody testing, and possibly thyroid ultrasound, can help identify the underlying cause of the thyroid enlargement. These tests can include assessments of thyroid hormone levels (T3, T4, and TSH), antibodies, and imaging studies. Requesting diagnostic laboratory testing is essential to accurately diagnose the condition and guide appropriate management and treatment.
Choice B Reason:
Obtaining a dietary consultation for nutrition teaching is inappropriate action. While nutrition can play a role in overall thyroid health, obtaining a dietary consultation for nutrition teaching is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Dietary consultation may be considered as part of comprehensive care for thyroid disorders, but it does not address the need for further evaluation and diagnosis of the thyroid enlargement.
Choice C Reason:
Instructing the client in the need to use iodized salt is inappropriate action. While iodine deficiency can contribute to thyroid disorders, instructing the client to use iodized salt is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Using iodized salt may help prevent iodine deficiency, but it does not address the need for further evaluation and diagnosis of the thyroid enlargement.
Choice D Reason:
Scheduling a follow-up appointment in one month is inappropriate action. While scheduling a follow-up appointment may be necessary for ongoing monitoring and management of thyroid disorders, it is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Further evaluation and diagnostic testing should be prioritized to determine the underlying cause of the thyroid enlargement and initiate appropriate treatment.

A. Black tarry stools. B. A cloudy discharge. C. An overactive bladder D. A weak urinary stream.

Correct Answer is D

Explanation

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.

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The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a physical assessment, palpation reveals to the clinic nurse that a client has an enlarged thyroid gland. What action should the nurse take in response to this finding?

Correct Answer is A

Explanation

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?

Correct Answer is D

Explanation

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