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
Explanation
Choice A: Obtain a 12-lead ECG
Obtaining a 12-lead ECG is a critical action when a client has a potassium level of 6.8 mEq/L, which indicates hyperkalemia. Hyperkalemia can cause serious cardiac dysrhythmias, including life-threatening arrhythmias such as ventricular fibrillation or asystole. An ECG can help detect these abnormalities early, allowing for prompt intervention to prevent cardiac complications. The ECG may show characteristic changes such as peaked T waves, widened QRS complexes, and prolonged PR intervals, which are indicative of hyperkalemia.
Choice B: Suggest that the client use a salt substitute
Suggesting that the client use a salt substitute is not appropriate in this situation. Many salt substitutes contain potassium chloride, which can further increase the potassium level in the blood. For a client with hyperkalemia, it is crucial to avoid additional sources of potassium to prevent exacerbating the condition. Therefore, recommending a salt substitute could be harmful.
Choice C: Advise the client to add citrus juices and bananas to her diet
Advising the client to add citrus juices and bananas to her diet is also inappropriate. Both citrus juices and bananas are high in potassium and can contribute to an increase in serum potassium levels. For a client with hyperkalemia, it is essential to limit dietary potassium intake to help lower the potassium levels in the blood. Encouraging the consumption of high-potassium foods would be counterproductive and potentially dangerous.
Choice D: Obtain a blood sample for a serum sodium level
While obtaining a blood sample for a serum sodium level can be part of a comprehensive assessment, it is not the immediate priority in managing hyperkalemia. The primary concern with a potassium level of 6.8 mEq/L is the risk of cardiac dysrhythmias. Therefore, obtaining an ECG to monitor the heart’s electrical activity is the most urgent and appropriate action. Once the immediate risk is addressed, further laboratory tests, including serum sodium levels, can be conducted as part of the overall assessment and management plan.
Correct Answer is D
Explanation
Choice A reason: A client who has Guillain-Barré syndrome:
Guillain-Barré syndrome (GBS) can cause significant muscle weakness and paralysis, including the muscles involved in swallowing. Clients with GBS are at high risk for aspiration and may require specialized feeding techniques or assistance from a nurse rather than an AP.
Choice B reason: A client who has systemic sclerosis:
Systemic sclerosis, also known as scleroderma, can affect the esophagus and cause difficulty swallowing. These clients may need careful monitoring and assistance with meals to prevent choking and ensure adequate nutrition.
Choice C reason: A client who has amyotrophic lateral sclerosis (ALS):
ALS affects the motor neurons and can lead to progressive muscle weakness, including the muscles involved in swallowing. Clients with ALS often require specialized feeding techniques and close monitoring during meals to prevent aspiration.
Choice D reason: A client who has a lumbosacral spinal tumor:
A lumbosacral spinal tumor primarily affects the lower back and may cause pain or mobility issues, but it does not typically impair swallowing. Therefore, this client is the most appropriate for the AP to assist with meals, as they are less likely to have complications related to eating.