When caring for older adult clients at a long-term care facility, which of the following assessments should the nurse prioritize when evaluating for the risk and presence of urinary retention? (Select all that apply.)
 

A 45-year-old female patient is admitted to the emergency department with severe abdominal pain, fever, and nausea. She reports that the pain started suddenly and has progressively worsened. The healthcare provider suspects peritonitis and orders immediate interventions.

Physical examination

On examination, the patient has a distended abdomen, guarding, and rebound tenderness.

Her vital signs are as follows:

Temperature 102.4°F (39.1°C), Heart rate 120 bpm, Blood pressure 90/60 mmHg, and Respiratory rate 24 breaths per minute.

Which of the following complications is the nurse's highest priority to monitor for in this patient?

A female client presents to the clinic with complaints of foul-smelling urine, a low-grade fever of 37.7° C (100° F), and dysuria for the past three days. She also reports increased urinary frequency and urgency but states that she has not noticed any blood in her urine. Upon examination. the nurse notes mild CVA tenderness on the right side. The nurse reviews the client's recent medical history, noting that she has a history of recurrent urinary tract infections (UTIs) and is currently taking no medications other than a daily multivitamin.

Vital Signs

blood pressure 120/78 mm Hg

heart rate 88 beats per minute

respiratory rate 18 breaths per minute

temperature 37.7° C (100° F)

During the process of collecting a comprehensive medical history from a client who has been admitted with pyelonephritis, which of the following symptoms or historical details would the nurse most likely expect the client to report?

A 55-year-old male patient presents to the emergency department with complaints of acute gastrointestinal (GI) bleeding. The patient reports passing black, tarry stools and experiencing dizziness and weakness. On physical examination, he is pale and diaphoretic.

Which of the following are the most appropriate initial nursing interventions for this patient? (Select all that apply)

A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority?

A female patient recently underwent a partial gastrectomy and is now presenting with symptoms of weakness, dizziness, and sweating, particularly after meals. Based on these symptoms, what is the most likely diagnosis?

A nurse is caring for a client who reports to the clinic for laboratory tests. The client has an acute kidney injury caused by acute tubular necrosis and asks why their glomerular filtration rate keeps decreasing. Which of the following pathophysiological changes occurring in the kidney should the nurse explain as the cause of decrease?

A nurse is assessing an older adult client who has a urinary tract infection (UTI). Which of the following findings should the nurse identify as unique for this age group?

A patient with acute pancreatitis is being discharged from the hospital. Which statement made by the patient indicates a need for further teaching regarding their discharge instructions?

A female patient presents with epigastric pain and is being evaluated for peptic ulcer disease (PUD). Upon reviewing her history, which of the following risk factors would be most indicative of increasing his likelihood of developing PUD?