A male client tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement?

Correct Answer: B

Rationale: In this scenario, the correct action for the nurse to implement is to select option B: Obtain a specimen of urethral drainage for culture. This is the most appropriate initial action as the client is presenting with symptoms suggestive of a possible urinary tract infection (UTI) or a sexually transmitted infection (STI) following unprotected sexual intercourse. By obtaining a specimen for culture, the nurse can identify the causative organism and guide appropriate treatment. Option A, observing the perineal area for a chancroid-like lesion, is incorrect because the client's symptoms do not specifically suggest the presence of a chancroid lesion, and obtaining a urethral culture is a more direct way to diagnose a possible infection. Option C, assessing for perineal itching, erythema, and excoriation, while relevant, does not address the need for a definitive diagnosis through a urethral culture. Option D, identifying all sexual partners in the last four days, is important for contact tracing and counseling but is not the immediate priority in this situation. From an educational standpoint, this question highlights the importance of thorough assessment and appropriate interventions in clients presenting with genitourinary symptoms following sexual activity. It emphasizes the need for nurses to consider both UTIs and STIs in the differential diagnosis and to prioritize diagnostic testing to guide treatment decisions effectively.

Correct Answer: B

Rationale: In this scenario, option B, Carotid bruit, is the correct answer indicating a client at risk for a brain attack (stroke). A carotid bruit is an abnormal sound heard when auscultating the carotid artery, which can indicate turbulent blood flow due to atherosclerosis, a major risk factor for stroke. This finding is significant because it suggests potential narrowing or blockage of the carotid artery, increasing the risk of emboli formation and subsequent stroke. Option A, nuchal rigidity, is associated with meningitis, not specifically with an increased risk for stroke. Option C, jugular vein distention, is more related to cardiovascular conditions like heart failure, not a direct indicator of stroke risk. Option D, palpable cervical lymph node, is more indicative of a localized infection or inflammation, not directly linked to stroke risk assessment. In an educational context, understanding these assessment findings and their significance in differentiating between various health conditions is crucial for pediatric nurses caring for patients with cardiovascular disorders. Being able to recognize these signs accurately can lead to timely interventions and prevention strategies, ultimately improving patient outcomes.

Correct Answer: A

Rationale: The correct answer is A) Invite friends over regularly to share in meal times. This option is the best choice because it addresses a potential psychosocial factor contributing to the weight loss of the client with Parkinson's disease. Parkinson's disease can lead to social isolation, depression, and decreased appetite, which can all contribute to weight loss. By inviting friends over for meals, the client is more likely to have social interaction, which can improve mood and appetite. Option B) Encouraging the client to drink clear liquids between meals does not directly address the underlying issue of weight loss in Parkinson's disease. While hydration is important, it does not specifically target the potential causes of weight loss in this case. Option C) Coaching the client to make an intentional effort to swallow is not the most appropriate response as it assumes the weight loss is solely due to swallowing difficulties, which may not be the case for this client. Option D) Talking to the healthcare provider about prescribing an appetite stimulant should be considered if other interventions do not work; however, it should not be the first line of action. Encouraging social interaction and a supportive environment during meals can be more effective in addressing weight loss in this situation. In an educational context, understanding the multifactorial nature of weight loss in clients with Parkinson's disease is crucial for nurses caring for these individuals. Providing holistic care that addresses not only physical symptoms but also psychosocial aspects can lead to better outcomes for the client.

Correct Answer: C

Rationale: In the scenario of a client with a liver abscess undergoing surgical evacuation and drainage, the most important laboratory value for the nurse to monitor following the procedure is the white blood cell count (WBC). Rationale for selecting white blood cell count (WBC): 1. Infections, such as a liver abscess, trigger an inflammatory response leading to an increase in WBC count, specifically neutrophils. Monitoring the WBC count post-surgery helps assess the body's response to the infection and the effectiveness of treatment. Reasons for eliminating other options: A) Serum creatinine: While important for assessing kidney function, it is not directly related to monitoring for post-surgical complications of a liver abscess. B) Blood urea nitrogen (BUN): Primarily indicates kidney function and hydration status, not the immediate concern post-surgical drainage of a liver abscess. D) Serum glucose: Monitoring glucose levels is crucial in diabetic patients or those at risk of hypoglycemia, but it is not the priority in this scenario. Educational context: Understanding the rationale behind monitoring specific laboratory values post-surgery is crucial for nurses caring for pediatric patients with cardiovascular disorders. This knowledge ensures timely identification of complications, appropriate interventions, and improved patient outcomes. Regular assessment and interpretation of laboratory values are essential skills for pediatric nurses to provide safe and effective care.

Correct Answer: A

Rationale: In this scenario, the correct assessment data the nurse should obtain next is blood pressure (Option A). Pheochromocytoma is a catecholamine-secreting tumor that can cause severe hypertension, leading to symptoms such as severe headaches and diaphoresis. Monitoring the client's blood pressure is crucial in this situation to assess for hypertensive crisis, which can be life-threatening if not managed promptly. Blood glucose level (Option B) is not the priority in this case as the client's symptoms are more indicative of a cardiovascular issue related to pheochromocytoma rather than a metabolic issue. Respiratory rate (Option C) and oxygen saturation (Option D) are important assessments, but in this context, the client's presentation of severe headache and diaphoresis points more towards a cardiovascular concern related to the pheochromocytoma. However, respiratory rate and oxygen saturation should still be monitored as part of the overall assessment. Educationally, understanding the specific signs and symptoms of pheochromocytoma and related cardiovascular disorders in pediatric patients is crucial for nurses working in pediatric settings. This rationale highlights the importance of prioritizing assessments based on the client's presenting symptoms to provide timely and appropriate care.