A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings?
Painful urination
Urge incontinence
Critically elevated prostate-specific antigen (PSA) level
Difficulty starting the flow of urine
The Correct Answer is D
Choice A: Painful urination
Painful urination, or dysuria, is not a typical symptom of benign prostatic hyperplasia (BPH). BPH primarily affects the flow of urine due to the enlargement of the prostate gland, which can obstruct the urethra. While BPH can cause discomfort, it does not usually result in painful urination. Painful urination is more commonly associated with urinary tract infections (UTIs) or other conditions affecting the urinary tract.
Choice B: Urge incontinence
Urge incontinence, characterized by a sudden and intense urge to urinate followed by involuntary loss of urine, can occur in some cases of BPH but is not the most common symptom. BPH typically causes symptoms related to urinary obstruction, such as difficulty starting urination, weak urine stream, and incomplete bladder emptying. Urge incontinence may develop if the bladder becomes overactive due to the obstruction, but it is not a primary symptom.
Choice C: Critically elevated prostate-specific antigen (PSA) level
While an elevated prostate-specific antigen (PSA) level can be associated with BPH, it is not a definitive finding. PSA levels can be elevated due to various conditions, including prostate cancer, prostatitis, and BPH. However, a critically elevated PSA level is more concerning for prostate cancer rather than BPH. Therefore, while PSA testing is useful in the evaluation of prostate conditions, it is not specific to BPH.
Choice D: Difficulty starting the flow of urine
Difficulty starting the flow of urine, also known as hesitancy, is a hallmark symptom of BPH. The enlarged prostate gland can compress the urethra, making it difficult for urine to pass through. This can lead to a weak urine stream, straining to urinate, and a feeling of incomplete bladder emptying. These symptoms are collectively known as lower urinary tract symptoms (LUTS) and are commonly associated with BPH.
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Correct Answer is ["A","B","C","E"]
Explanation
Choice A: Evaluate for the presence of a Babinski reflex
The Babinski reflex, also known as the plantar reflex, is a normal reflex in infants up to 2 years old. When the sole of the foot is stroked, the big toe moves upward, and the other toes fan out. This reflex helps assess the neurological function and integrity of the corticospinal tract. In the context of a subdural hematoma, evaluating the Babinski reflex can help determine if there is any neurological impairment or increased intracranial pressure, which could indicate worsening of the condition.
Choice B: Measure the head circumference
Measuring the head circumference is crucial in infants, especially those with head injuries, as it helps monitor brain growth and detect any abnormal swelling or increased intracranial pressure. An increase in head circumference can indicate the presence of intracranial bleeding or edema, which requires immediate medical attention. Regular monitoring of head circumference allows healthcare providers to track the infant’s neurological development and identify any deviations from the normal growth curve.
Choice C: Assess the pupillary reaction to light
Assessing the pupillary reaction to light is an essential neurological assessment in infants with head injuries. The pupils’ response to light provides information about the function of the optic nerve and the brainstem. A normal pupillary reaction indicates that the brainstem is functioning correctly, while an abnormal reaction can suggest increased intracranial pressure or brain injury. In this case, the nurse should assess the pupillary reaction to ensure there are no signs of neurological deterioration.
Choice D: Encourage parents to feed the infant
Encouraging parents to feed the infant is not recommended in this scenario. The infant’s inability to awaken for feeding and sleeping through the vital sign assessment could indicate a decreased level of consciousness or neurological impairment. Feeding an infant in such a state could increase the risk of aspiration and further complications. Instead, the nurse should focus on monitoring the infant’s neurological status and ensuring their safety.
Choice E: Palpate fontanel level
Palpating the fontanel level is an important assessment in infants with head injuries. The fontanels, or soft spots on the infant’s skull, provide valuable information about intracranial pressure. A bulging fontanel can indicate increased intracranial pressure, while a sunken fontanel may suggest dehydration. In this case, the nurse should palpate the fontanel to assess for any abnormalities that could indicate changes in the infant’s condition.
Correct Answer is D
Explanation
Choice A: Take the Medication with Orange Juice
Taking betamethasone with orange juice is not specifically recommended. While orange juice can help with the taste of some medications, it does not have any particular benefit for betamethasone. Additionally, citrus juices can sometimes interfere with the absorption of certain medications.
Choice B: Take the Medication Between Meals
Taking betamethasone between meals is not advised. This medication can cause stomach upset, and taking it on an empty stomach can exacerbate this issue. It is generally recommended to take corticosteroids with food to minimize gastrointestinal discomfort.
Choice C: Take the Medication on an Empty Stomach
Taking betamethasone on an empty stomach is not recommended for the same reasons as above. It can lead to stomach irritation and discomfort. Taking the medication with food or milk helps to reduce these side effects.
Choice D: Take the Medication with Milk
Taking betamethasone with milk is the correct instruction. Milk can help to buffer the stomach lining and reduce the risk of gastrointestinal irritation, which is a common side effect of corticosteroids. This practice helps to ensure that the medication is tolerated well by the client.
