The RN is admitting a client to the medical unit for a urinary ...

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The RN is admitting a client to the medical unit for a urinary disorder. Which physical assessment techniques should the nurse use in assessing this client's urinary system?
 
  1. Auscultation and inspection
  2. Inspection and percussion
  3. Observation and auscultation
  4. Palpation and observation

Question 2

Which goals should the nurse identify as appropriate for a client with the nursing diagnosis Urinary Pattern Alteration related to an enlarged prostate?
 
  1. The client will avoid bladder distention.
  2. The client will maintain fluid imbalance.
  3. The client will remain free of skin breakdown.
  4. The client will voice increased discomfort.

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Answer to Question 1

Correct Answer: 4
Rationale 1: The nurse will not use auscultation when assessing the client's urinary system.
Rationale 2: The percussion technique is the least frequently used by nurses, and it would cause discomfort if this client is already uncomfortable with a kidney condition. The nurse should not make matters worse.
Rationale 3: The nurse will not use auscultation when assessing the client's urinary system.
Rationale 4: The hands and sense of touch are used with palpation to gather data along with observation or inspection, which visually allows the nurse to observe all responses and nonverbal behavior. It is also the most frequently used technique and the most convenient.

Answer to Question 2

Correct Answer: 1
Rationale 1: Avoiding bladder distention will help eliminate stasis of urine in the bladder, which contributes to urinary tract infections, a possible complication of urine flow being obstructed from an enlarged prostate.
Rationale 2: One would want to maintain fluid balance, not imbalance, with a client with urinary obstruction and enlarged prostate. Keeping up with the client's intake and output would be a better goal.
Rationale 3: It is important to keep urine off the skin to prevent breakdown, but with an enlarged prostate the problem will be more of the client retaining urine instead of it being on the skin.
Rationale 4: One would hope that if the retention subsides, the client would voice less discomfort, not more.