Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.).
A. Distended bladder.
A distended bladder is a common sign of urinary retention, which can occur with prostatic hypertrophy. The enlarged prostate can block the flow of urine, causing the bladder to become distended.
B. Dysuria.
Dysuria, or painful urination, is not typically associated with urinary retention. It is more commonly seen in urinary tract infections.
C. Report of feeling pressure.
Feeling pressure is a common symptom of urinary retention. The pressure is caused by the buildup of urine in the bladder.
D. Voiding 30 mL frequently.
Voiding small amounts frequently can be a sign of urinary retention. The bladder is not able to fully empty, so small amounts of urine are passed frequently.
E. Tenderness over the symphysis pubis.
Tenderness over the symphysis pubis can be a sign of a distended bladder. The bladder is located just behind the symphysis pubis, so distention can cause tenderness in this area.
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Full Explanation
Choice A rationale:
A distended bladder is a common sign of urinary retention, which can occur with prostatic hypertrophy. The enlarged prostate can block the flow of urine, causing the bladder to become distended.
Choice B rationale:
Dysuria, or painful urination, is not typically associated with urinary retention. It is more commonly seen in urinary tract infections.
Choice C rationale:
Feeling pressure is a common symptom of urinary retention. The pressure is caused by the buildup of urine in the bladder.
Choice D rationale:
Voiding small amounts frequently can be a sign of urinary retention. The bladder is not able to fully empty, so small amounts of urine are passed frequently.
Choice E rationale:
Tenderness over the symphysis pubis can be a sign of a distended bladder. The bladder is located just behind the symphysis pubis, so distention can cause tenderness in this area.
Similar Questions
A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting.
The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect?
A. Thrombotic stroke.
A thrombotic stroke occurs when a blood clot forms in one of the arteries that supply blood to the brain. It does not typically cause a sudden, severe headache and vomiting.
B. Transient ischemic attack (TIA).
A transient ischemic attack (TIA), or “mini-stroke,” is a temporary blockage of blood flow to the brain. It does not cause a sudden, severe headache and vomiting.
C. Hemorrhagic stroke.
A hemorrhagic stroke occurs when a blood vessel in the brain bursts, causing bleeding into the brain. This can cause a sudden, severe headache and vomiting.
D. Embolic stroke.
An embolic stroke occurs when a blood clot or other debris forms away from your brain — commonly in your heart — and is swept through your bloodstream to lodge in narrower brain arteries. This type of stroke does not typically cause a sudden, severe headache and vomiting.
Full Explanation
Choice A rationale:
A thrombotic stroke occurs when a blood clot forms in one of the arteries that supply blood to the brain. It does not typically cause a sudden, severe headache and vomiting.
Choice B rationale:
A transient ischemic attack (TIA), or “mini-stroke,” is a temporary blockage of blood flow to the brain. It does not cause a sudden, severe headache and vomiting.
Choice C rationale:
A hemorrhagic stroke occurs when a blood vessel in the brain bursts, causing bleeding into the brain. This can cause a sudden, severe headache and vomiting.
Choice D rationale:
An embolic stroke occurs when a blood clot or other debris forms away from your brain — commonly in your heart — and is swept through your bloodstream to lodge in narrower brain arteries. This type of stroke does not typically cause a sudden, severe headache and vomiting.
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy.
The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
A. Heart rate
A decrease in heart rate is an indication of adequate fluid replacement. As fluid volume is restored, the heart does not have to work as hard to pump blood, so the heart rate decreases.
B. Blood pressure
Blood pressure is not a reliable indicator of fluid volume status. It can be influenced by many factors, including pain, anxiety, and medications.
C. Weight
Weight is not a reliable indicator of fluid volume status in the short term. It can take several days for changes in fluid volume to be reflected in weight.
D. Urine output
Urine output is a good indicator of kidney function, but it is not a reliable indicator of fluid volume status. Many factors can influence urine output, including kidney function, fluid intake, and medications.
Full Explanation
Choice A rationale:
A decrease in heart rate is an indication of adequate fluid replacement. As fluid volume is restored, the heart does not have to work as hard to pump blood, so the heart rate decreases.
Choice B rationale:
Blood pressure is not a reliable indicator of fluid volume status. It can be influenced by many factors, including pain, anxiety, and medications.
Choice C rationale:
Weight is not a reliable indicator of fluid volume status in the short term. It can take several days for changes in fluid volume to be reflected in weight.
Choice D rationale:
Urine output is a good indicator of kidney function, but it is not a reliable indicator of fluid volume status. Many factors can influence urine output, including kidney function, fluid intake, and medications.
A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet.
Which of the following nursing actions should the nurse take to promote the client's comfort?
A. Obtain a pair of slipper-socks for the client.
Providing warm slipper-socks can help increase the client’s comfort by keeping their feet warm.
B. Increase the client's oral fluid intake.
Increasing the client’s oral fluid intake would not directly affect the temperature of their feet.
C. Rub the client's feet briskly for several minutes.
Rubbing the client’s feet briskly for several minutes could potentially harm the client, especially if they have decreased sensation in their feet due to peripheral vascular disease.
D. Place a moist heating pad under the client's feet.
Placing a moist heating pad under the client’s feet could potentially burn the client, especially if they have decreased sensation in their feet due to peripheral vascular disease.
Full Explanation
Choice A rationale:
Providing warm slipper-socks can help increase the client’s comfort by keeping their feet warm.
Choice B rationale:
Increasing the client’s oral fluid intake would not directly affect the temperature of their feet.
Choice C rationale:
Rubbing the client’s feet briskly for several minutes could potentially harm the client, especially if they have decreased sensation in their feet due to peripheral vascular disease.
Choice D rationale:
Placing a moist heating pad under the client’s feet could potentially burn the client, especially if they have decreased sensation in their feet due to peripheral vascular disease.