Male and Female Assessment
This common older-male condition causes nocturia, urinary hesitancy, weak stream, and post-void dribbling due to gland enlargement.
What is benign prostatic hyperplasia (BPH)?
This category of basic self-care tasks includes bathing, dressing, toileting, transferring, continence, and feeding.
What are Activities of Daily Living (ADLs)?
This yellowish discoloration of the skin and sclera indicates elevated bilirubin.
What is jaundice?
A client has 3/5 muscle strength in the right leg. What does this indicate?
What is movement against gravity but not against resistance?
"Can you tell me more about your pain?" is an example of this communication technique.
What is exploring?
Before a provider performs a prostate or genital exam, the nurse does these three things for the client.
What are explain the procedure, ensure privacy, and assist with positioning/draping?
Managing finances, taking medications correctly, shopping, cooking, and using transportation are all examples of this category.
What are Instrumental Activities of Daily Living (IADLs)?
This scale is commonly used to identify a patient's risk level for developing a pressure injury.
What is the Braden Scale?
During a mobility assessment, a client becomes unsteady while ambulating. What is the nurse's priority action?
What is assist the client to a safe position to prevent a fall?
When obtaining a health history, the nurse should document the client's symptoms using these.
What are the client's own words (quotation marks when appropriate)?
A prostate that feels hard, irregular, nodular, or fixed on exam should prompt the nurse to do this.
What is notify the provider promptly (possible malignancy)?
Slower reaction time, decreased balance, a slower/shuffling gait, and diminished vibration sense are all normal changes of this life stage that raise fall risk.
What is older adulthood (age-related physiologic change)?
A client has non-blanchable redness over the sacrum. This finding is consistent with...
What is a Stage 1 pressure injury?
This part of the nervous system controls voluntary skeletal muscle movement.
What is the somatic nervous system?
A client says, "I'm really scared about my surgery." Which response is therapeutic?
What is "Tell me more about what worries you."
Foul-smelling vaginal discharge, a visible lesion, or a palpable mass found during assessment should be treated this way.
What is an abnormal finding requiring further evaluation/provider notification?
An older adult reports falling twice this month. What assessment is the priority?
What is a fall risk assessment?
The nurse notes tenting of the skin over the clavicle in an older adult. What should the nurse suspect?
What is dehydration?
An older adult suddenly becomes confused, has slurred speech, and a facial droop. What is the nurse's priority?
What is recognize a possible stroke and seek immediate medical evaluation?
A client becomes quiet after discussing a recent diagnosis. What is the nurse's best response?
What is use therapeutic silence and remain present?
A client reports burning with urination. What assessment question should the nurse ask next?
Are you having any urinary frequency or urgency
The "Get Up and Go" test primarily evaluates these abilities.
What are mobility, balance, and gait?
An older adult's skin is cool, pale, and capillary refill is greater than 3 seconds. What does the nurse suspect?
What is decreased peripheral perfusion?
A shortened, externally rotated leg after a fall suggests this injury.
What is a hip fracture?
The client says, "I'm short of breath." Which question best assesses severity?