Which findings should the nurse follow up on afterremoval of a catheter from a patient? (Select allthat apply.)

Correct Answer: B

Rationale: The correct answer is B: Dribbling of urine. This finding should be followed up on after catheter removal because it may indicate urinary retention or incomplete bladder emptying, which can lead to complications such as urinary tract infection. A: Increasing fluid intake is important for overall hydration but is not a specific finding that requires follow-up after catheter removal. C: Voiding in small amounts may be a normal response initially after catheter removal and does not necessarily indicate a problem. D: Voiding within 6 hours of catheter removal is a positive sign of bladder function recovery and does not require immediate follow-up.

Correct Answer: D

Rationale: The correct answer is D: Ensuring patient privacy. In the PLISSIT model, ensuring patient privacy is crucial as it creates a safe and confidential environment for discussing sensitive topics like sexual health. This step helps build trust and allows the patient to feel comfortable sharing intimate details. Briefly teaching about normal sexual physiology (A) may come later in the assessment process. Assuring confidentiality (B) is important but doesn't address the immediate need for privacy. Asking if the patient is willing to discuss sexual functioning (C) assumes patient readiness without first establishing a private setting.

Correct Answer: B

Rationale: The correct answer is B: Medication adverse effects. Gynecomastia in a 60-year-old man is often caused by medications like spironolactone, cimetidine, and certain antipsychotics. To determine the causative factor, a thorough medication history review is crucial. Age-related physiologic changes (choice A) do not typically lead to gynecomastia in men. Poor nutrition (choice C) and fluid overload (choice D) are not common causes of gynecomastia in this context.

Correct Answer: C

Rationale: The correct answer is C: Prostatitis. The patient's symptoms of perineal discomfort, burning, urgency, frequency with urination, and pain with ejaculation are indicative of prostatitis. Prostatitis is inflammation of the prostate gland, leading to these symptoms. Varicocele (A) is an enlargement of the veins within the scrotum, usually painless. Epididymitis (B) is inflammation of the epididymis, causing scrotal pain and swelling. Hydrocele (D) is a fluid-filled sac around the testicle, typically painless. The patient's symptoms align most closely with prostatitis due to the involvement of the prostate gland and the specific urinary and ejaculatory symptoms experienced.

Correct Answer: C

Rationale: The correct answer is C because providing realistic emotional preparation for death is a priority in caring for a patient with a terminal illness like leukemia. This helps the patient and their loved ones cope with the impending loss and make the most of the time left. Option A focuses solely on prolonging life, which may not align with the patient's wishes. Option B, providing financial advice, is important but not the top priority in this situation. Option D, maximizing family social interactions after the patient's death, is not immediate and does not address the patient's emotional needs.

Correct Answer: D

Rationale: The correct answer is D: Bacteria. In a patient with a urinary tract infection (UTI), bacteria are typically present in the urine due to the infection of the urinary system. Bacteria may be detected through urine culture or microscopic examination. A: Casts are not typically associated with UTIs but can indicate kidney disease. B: Protein in the urine can indicate kidney damage or other issues, not specific to UTIs. C: Crystals in the urine can be normal or indicate specific conditions, but they are not specific to UTIs. In summary, the presence of bacteria in the urine is a key indicator of a UTI, while the other choices are more indicative of different conditions or factors.

Correct Answer: A

Rationale: Rationale for Correct Answer A: Applying a protective eye shield at night is crucial for a patient with Bell's palsy to prevent corneal abrasions due to incomplete eyelid closure. This action helps protect the eye from dryness and injury, which can occur due to decreased blinking and moisture. It is essential to maintain eye health and prevent complications. Summary of Incorrect Choices: B: Chewing on the affected side does not prevent unilateral neglect in Bell's palsy. Instead, encouraging balanced chewing and facial exercises would be more beneficial. C: Avoiding the use of analgesics is not necessary for Bell's palsy management unless contraindicated, as pain management may be required for associated symptoms. D: Avoiding brushing the teeth is not recommended. Good oral hygiene is important for overall health, including maintaining oral health during Bell's palsy.

Correct Answer: C

Rationale: The correct answer is C: "You are anxious about the surgery. Do you see smoking as helping?" This response acknowledges the patient's anxiety and invites him to explore his reasons for wanting to smoke, opening up a dialogue and potentially uncovering underlying issues. It also avoids judgment or direct orders, fostering a therapeutic nurse-patient relationship. Explanation of why the other choices are incorrect: A: "Smoking is the reason you are here." - This response is blaming and may increase the patient's guilt or anxiety, hindering effective communication. B: "The doctor left orders for you not to smoke." - This response is authoritative and may lead to resistance or defensiveness from the patient, rather than addressing his concerns. D: "Smoking is OK right now, but after your surgery it is contraindicated." - This response is unclear and may send mixed messages to the patient, potentially leading to confusion or misunderstanding.

Correct Answer: A

Rationale: The correct answer is A: Serum albumin level. Serum albumin is an important indicator of nutritional status, as low levels may indicate malnutrition or inflammation commonly seen in AIDS patients. Weight history (B) is also relevant as weight changes can reflect nutritional status. White blood cell count (C) is not directly related to nutritional status. Body mass index (D) is a calculation based on weight and height, not a direct measure of nutritional status. Blood urea nitrogen (E) is a measure of kidney function, not a specific indicator of nutritional status. Therefore, the nurse should primarily focus on assessing the patient's serum albumin level for nutritional status evaluation in this case.