Chapter 22 Physical Assessment

The nurse is preparing to catheterize a client who has just voided. Which is the purpose of this catheterization? 1. To obtain a baseline urine output. 2. To support the diagnosis of kidney stones. 3. To evaluate the ability of the client to empty the bladder. 4. To evaluate renal function.

3

A client has a spinal cord injury with paralysis at C5 level. When completing discharge teaching, which client statement would require further teaching? 1. "I need to perform self-catheterization three times daily." 2. "I know I cannot look to see if my bladder is full." 3. "I need to avoid bladder distention." 4. "I'll drink adequate amounts of liquids."

1

A client is admitted with possible renal calculi. The client asks, "Are there are any tests that can be performed to show the doctor if there are any kidney stones?" Which response by the nurse is the most appropriate? 1. "The intravenous pyelogram will allow the healthcare provider to visualize kidney stones." 2. "A 24-hour urine specimen will allow the healthcare provider to visualize kidney stones." 3. "A routine urinalysis will allow the healthcare provider to visualize kidney stones." 4. "A kidney biopsy will allow the healthcare provider to visualize kidney stones."

1

A postpartum client with a difficult vaginal delivery 36 hours ago tells the nurse that she has not felt the need to void much since delivery. Which response by the nurse is the most appropriate? 1. "The inside of your bladder is most likely swollen, which makes you feel like you don't have to urinate." 2. "You must be overdoing it with your activity level so soon after delivery." 3. "I will need to catheterize you." 4. "Your uterus must not be enlarged any longer."

1

During the assessment of a client with multiple injuries, the nurse notices a large hematoma located at the left costovertebral angle. The nurse should suspect injury to which organ? 1. Kidney. 2. Ribs. 3. Intestines. 4. Bladder.

1

During the assessment of a client's urinary system, the nurse learns that the client has painful urination. Which term will the nurse use when documenting this finding in the client's medical record? 1. Dysuria. 2. Hematuria. 3. Oliguria. 4. Polyuria.

1

Since returning from surgery the client has not voided for 8 hours; therefore, the nurse determines it is necessary to assess the client for bladder distention. Which client position is appropriate for this assessment? 1. Supine with only a small pillow under their head. 2. Prone position. 3. Sitting in bed at a 45-degree angle. 4. Lying in a left lateral position.

1

The nurse is assessing a client after a motor vehicle accident and notes the presence of ecchymosis in the left flank area. Which interpretation of this data is the most accurate? 1. Positive Grey Turner sign. 2. Costovertebral angle tenderness. 3. Possible clotting dysfunction. 4. A precursor to hematuria.

1

The nurse is caring for an infant with newly diagnosed renal disease. Diagnostic tests for which system is the priority for this infant? 1. Ears. 2. Heart. 3. Lungs. 4. Joints.

1

The nurse is interviewing the parents of a toddler who state they are concerned about the child's bedwetting. Which response by the nurse is the most appropriate? 1. ""Be sure to limit the child's fluid intake during the evening." 2. "Don't worry; all children wet the bed." 3. "We'll obtain a specimen to check for a urinary tract infection." 4. "This problem will be gone at the age of 4."

1

The nurse is palpating the left flank area and feels a sharp edge with definite delineated margins. Based on this data, which is the nurse palpating? 1. An enlarged spleen. 2. An enlarged kidney. 3. The colon. 4. A distended bladder.

1

A client presents with a medical diagnosis of uremia. Which clinical manifestations does the nurse anticipate upon assessment? Standard Text: Select all that apply. 1. Itching. 2. Weight loss. 3. Altered mental status. 4. Fluid retention. 5. Insomnia.

1, 2, 3, 4

The nurse is interviewing a client regarding urinary health. Which response would the nurse include during the collection of subjective data? Standard Text: Select all that apply. 1. "Do you have difficulty starting your stream of urine?" 2. "After you urinate, does your bladder feel full or empty?" 3. "Do you ever have an accident or wet yourself when you sneeze?" 4. "Do you have to hurry to the bathroom when you have to urinate?" 5. "Your recent urinalysis reveals protein in the urine."

1, 2, 3, 4

The nurse is preparing a client for assessment of the urinary system. Which technique will the nurse include in this physical assessment? Standard Text: Select all that apply. 1. Inspection. 2. Palpation. 3. Percussion. 4. Auscultation. 5. Client interview.

1, 2, 3, 4

The nurse is preparing an educational session on kidney health for a church group. Which would the nurse include as the leading causes of end-stage renal disease? Standard Text: Select all that apply. 1. Diabetes mellitus. 2. Alcoholism. 3. Hypertension. 4. Cardiovascular disease. 5. Obesity.

1, 3

The nurse is assessing a client admitted for oliguria of unknown origin. During the admission, the client asks the nurse what affects urinary output. Which responses are appropriate by the nurse? Standard Text: Select all that apply. 1. Bladder size. 2. Bowel patterns. 3. Medications. 4. Client temperature. 5. Fluid intake.

1, 3, 4, 5

A client's blood pressure suddenly falls from 120/80 mmHg to 90/60 mmHg. Which major role of the kidney is causing this clinical manifestation? 1. Increasing hydrostatic pressure. 2. Release of renin. 3. Increasing glomerular filtration rate. 4. Dilation of renal vessels.

2

An older adult female comes into the clinic to be seen for urinary incontinence. Which conclusion by the nurse is the most appropriate? 1. Is common with aging. 2. Often occurs as a secondary problem. 3. Indicates decreased renal blood flow. 4. Is related to medications.

2

The nurse is admitting a client with constant, severe flank pain, spasms, nausea and vomiting, and oliguria. The client states that the pain was initially intermittent and radiated from the low back to the lower quadrants of the abdomen. Which nursing action is the priority for this client? 1. Administer pain medication. 2. Notify the healthcare provider immediately. 3. Obtain a urine specimen for culture. 4. Complete the assessment.

2

The nurse is obtaining a medication history on a newly admitted client with renal dysfunction. Which medication classification would the nurse note as significant for this client? 1. Antihypertensives. 2. Analgesics. 3. Antihyperlipidemics. 4. Diuretics.

2

The nurse is percussing over the client's symphysis pubis area and notes a dull tone. Which conclusion by the nurse is the most appropriate based on the data? 1. He or she is assessing the right kidney. 2. A full bladder. 3. A bladder tumor. 4. Air trapped in the intestines.

2

During the assessment of a client's renal system, the nurse is unable to palpate the kidneys. Which conclusion by the nurse is the most appropriate? 1. An indication of an inflammatory condition of the kidneys. 2. A sign of acute or chronic renal disease. 3. Normal. 4. A sign of polycystic kidney disease.

3

The nurse is interviewing a client who states the presence of urinary incontinence with coughing and sneezing. Which term will the nurse use when documenting this finding in the medical record? 1. Functional. 2. Reflex. 3. Stress. 4. Urge.

3

The nurse is interviewing an older adult client in the clinic who reports incontinence. Numerous attempts in the recent past have been unsuccessful in helping to control the problem. Which is the priority diagnosis for this client? 1. Skin integrity impairment. 2. Self-care deficit. 3. Self-esteem, situational-low. 4. Infection.

3

The nurse is preparing an educational session on kidney health for a church group. Which group would the nurse note to have the highest incidence of end-stage renal disease? 1. Mexicans. 2. Asians. 3. African Americans. 4. American Indians.

3

An adolescent visits the school nurse to ask why she is getting frequent urinary tract infections. Which questions should the nurse ask the client during this visit? Standard Text: Select all that apply. 1. "Have you been eating foods that have high acidity?" 2. "Do you drink a lot of milk?" 3. "Do you take bubble baths frequently?" 4. "What direction do you wipe after a bowel movement?" 5. "Do you have a family history of urinary tract infections?"

3, 4

A client experienced blood loss from surgery. What is the impact of this blood loss on the kidney's functioning? 1. Altered filtering ability of the kidneys. 2. No impact on kidney function. 3. Absorption of calcium and phosphate decreased. 4. Stimulation of the kidneys to produce erythropoietin.

4

The nurse is able to percuss a dull tone over a client's bladder after the client has voided 300 ml of urine. Which conclusion by the nurse is the most appropriate? 1. This is a normal finding. 2. Possible urinary tract infection. 3. This is a sign of prostate enlargement. 4. Probable urinary retention.

4

The nurse is caring for a client admitted with an infection of the ureters. The nurse realizes this infection could include which structure of the kidney? 1. Capsule. 2. Cortex. 3. Medulla. 4. Pelvis.

4

The nurse is collecting a urine specimen from a client and notes the urine is foamy and amber in color. Based on this data, which diagnosis would the nurse suspect? 1. Kidney stones. 2. Urinary tract infection. 3. Prostate disease. 4. Liver disease.

4

The nurse is measuring the urinary output for a client and notes 450 ml of urine. Which conclusion by the nurse is the most appropriate? 1. Decreased from normal. 2. Concentrated from what is normal. 3. Increased from normal. 4. Normal amount.

4

The nurse is teaching an adult client who is participating in rehabilitation for bladder retraining. Which amounts of urine would cause the bladder to distend above the symphisis pubis? 1. 100 ml. 2. 200 ml. 3. 500 ml. 4. 700 ml.

4