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

Auscultate an area six inches below the umbilicus.

Palpate the area above the pubic symphysis.

Measure the girth of the client's lower abdomen.

Observe the appearance of the client's urine.

Answer and Explanation

The Correct Answer is B

A. Auscultating below the umbilicus is not effective for assessing urinary retention.

B. Palpating the area above the pubic symphysis allows the nurse to assess for bladder distention, which is a direct indicator of urinary retention.

C. Measuring the girth of the lower abdomen can be useful but is less specific than palpation for assessing bladder fullness.

D. Observing the urine's appearance does not directly assess for urinary retention.

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Correct Answer is C

Explanation

A. Ensuring the correct placement of the nasogastric tube with an abdominal x-ray is important for treatment but does not address the infant's developmental needs.

B. Using sterile water for gastric lavage may be necessary for stomach decompression but does not directly support the infant's growth and development.

C. Offering a pacifier for non-nutritive sucking provides comfort and helps maintain the infant’s sucking reflex, which is crucial for feeding and oral development.

D. Physical therapy is not relevant for a 2-month-old infant with hypertrophic pyloric stenosis and does not address immediate developmental needs.

A. "Hyperglycemia often results in weight loss." B. "Hyperglycemia causes cool and clammy skin." C. "Hyperglycemia causes an increased sensation of being hungry." D. "Hyperglycemia causes a headache and flushed, dry skin." E. "Hyperglycemia often presents as increased thirst and urination."

Correct Answer is ["D","E"]

Explanation

A. "Hyperglycemia often results in weight loss.": Weight loss is more commonly associated with prolonged hyperglycemia, particularly in uncontrolled diabetes where the body starts breaking down fat and muscle for energy.

B. "Hyperglycemia causes cool and clammy skin.": Cool and clammy skin is more indicative of hypoglycemia (low blood sugar) rather than hyperglycemia.

C. "Hyperglycemia causes an increased sensation of being hungry.": Increased hunger is often associated with hypoglycemia or uncontrolled diabetes, where insulin is not effectively managing blood glucose levels.

D. "Hyperglycemia causes a headache and flushed, dry skin.": In cases of significant hyperglycemia, symptoms can include headache and flushed, dry skin due to dehydration. These symptoms arise from the body’s attempt to balance blood sugar levels and manage dehydration.

E. "Hyperglycemia often presents as increased thirst and urination.": Hyperglycemia typically leads to increased thirst (polydipsia) and increased urination (polyuria). This occurs because the body tries to get rid of excess glucose through the urine, leading to dehydration and increased thirst.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Patient Data Exhibits After the obstetrician leaves, the client appears confused and asks the nurse, "How will I know if I have high blood sugar?" Which are the nurse's best responses? Select all that apply.

Correct Answer is ["D","E"]

Explanation

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