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

Auscultate an area six inches below the umbilicus.

Observe the appearance of the patient’s urine.

Palpate the area above the pubic symphysis.

Measure the girth of the patient’s lower abdomen.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.

Choice B rationale

Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.

Choice C rationale

Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.

Choice D rationale

Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.

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Correct Answer is C

Explanation

Choice A rationale

Increased BUN and serum creatinine are not typically symptoms of mononucleosis. These laboratory findings are more commonly associated with kidney dysfunction.

Choice B rationale

Ear pain and fever can be symptoms of many illnesses, including mononucleosis. However, they are not the most specific symptoms of this condition.

Choice C rationale

A positive Epstein-Barr virus test and malaise are common symptoms of mononucleosis. The Epstein-Barr virus is the most common cause of mononucleosis.

Choice D rationale

Elevated WBC and sedimentation rate can be seen in many inflammatory or infectious conditions, including mononucleosis. However, they are not the most specific symptoms of this condition.

A. hospitalized for 2 weeks B. initially in the intensive care unit and has been moved to the surgical floor C. pain is rated as 2 on a 0 to 10 pain scale D. client has requested sleeping medication for the night E. keeps having distressing thoughts and memories about the house collapsing F. Now I can’t seem to get out of this funk I am in G. expressed a preference for a quieter area of the unit

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

Explanation

Based on the provided information, the following aspects of the assessment require urgent attention:

The client’s request for sleeping medication: This indicates that she is having trouble sleeping, which can affect her recovery.
The client’s distressing thoughts and memories about the house collapsing: This could be a sign of post-traumatic stress disorder (PTSD), which requires immediate attention and possibly referral to a mental health professional.
The client’s statement about being in a “funk”: This could indicate depression or another mental health issue, which should be addressed promptly.
The client’s preference for a quieter area of the unit: The noise by the nurses’ station is disturbing her rest, which is crucial for her recovery. Efforts should be made to accommodate her request if possible.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a child with mononucleosis.Which symptoms should the nurse expect the child to exhibit?

Correct Answer is C

Explanation

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

Explanation

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