Correct answer-C. Rationales: Most clients with renal calculi have blood in their urine from the stone’s passing. The urine is dark, tests Hemoccult positive, and is usually scant. Option B refers to an upper GI bleed, and option D refers to cholecystitis. Option A isn’t a precipitating factor relating to renal calculi.

Nursing process step: Assessment

Correct answer-C. Rationales: Pyelonephritis is diagnosed by the presence of leukocytosis, hematuria, pyuria, and bacteriuria. The client presents with fever, chills, and flank pain. Because the client is usually septic, the WBC count is more likely to be elevated, not low as indicated in option D. Ketonuria indicates a diabetic state as indicated in option B. Myoglobinuria, option A, indicates muscle wasting in rhabdomyolysis.

Nursing process step: Assessment

Correct answer-A. Rationales: Autonomic dysreflexia is a potentially life-threatening emergent situation that occurs in quadriplegics and high-cord-lesion (above T6) paraplegics. The priority is to lower the blood pressure by using nifedipine. Lowering the blood pressure should eliminate the headache. Meperidine doesn’t lower blood pressure. Verapamil is contraindicated because it’s used to treat supraventricular tachycardia. Heparin shouldn’t be used because of the potential for a cerebral or subarachnoid bleed from hypertension.

Nursing process step: Analysis

Correct answer-C. Rationales: Autonomic dysreflexia occurs as a result of autonomic responses to stimuli, after which sympathetic responses above the splanchnic outflow level are increased. The increase in turn causes cutaneous vasodilation above the cord lesion (flushing and excessive sweating) and cutaneous vasoconstriction below the lesion (pallor, coolness). Thus, the other options are incorrect.

Nursing process step: Assessment

Correct answer-D. Rationales: The most common cause of autonomic dysreflexia is bladder distention, but this client had an indwelling urinary catheter inserted 30 minutes before admission. Urine return was 100 mL, indicating that the bladder has been drained. The second most common cause of this condition is rectal distention from an impaction. Other causes include catheterization and catheter manipulation, cleansing enemas, acute abdominal or genitourinary pathology, temperature extremes, and skin lesions, such as pressure ulcers and ingrown toenails.

Nursing process step: Evaluation

Correct answer-C. Rationales: Heart failure and sepsis can decrease cardiac output. This decreased perfusion to the kidney can lead to acute renal failure. Renal calculi, urinary retention, and urethral strictures can be caused by obstruction in the renal urine collection system.

Nursing process step: Assessment

Correct answer-B. Rationales: The rule of therapy for a client with renal calculi is hydration and analgesia. Opioids are usually required to control the pain. The I.M. route may be used, but I.V. is preferred. I.V. fluids are provided to hydrate the client and help flush out the calculus. Option A provides only for a KVO rate; a faster rate is necessary to accomplish the goals. An indwelling urinary catheter and an NG tube are usually unnecessary.

Nursing process step: Analysis

Correct answer-C. Rationales: Bacterial infections aren’t a cause of priapism. Causes of priapism (a prolonged and painful penile erection that isn’t usually associated with sexual desire) include spinal cord injury, leukemia, and sickle cell disease. Other causes are psychotropic drugs, multiple sclerosis, prolonged sexual stimulation, penile or urethral tumor, anticoagulant therapy, and treatments for impotence.

Nursing process step: Assessment

Correct answer-C. Rationales: Epididymitis is suggested by hyperperfusion on testicular scan, an elevated white blood cell count, and the presence of bacteria in the urine. An elevated creatinine level is an indicator of renal, not scrotal, disease.

Nursing process step: Assessment

Correct answer-C. Rationales: Orthostatic hypotension can be a sign of hemorrhage and a precursor to hypovolemic shock. It’s a good test to use in the early phases of hemorrhage, when other symptomatology may be absent (a negative orthostatic test doesn’t rule out the possibility of bleeding). An increase in the pulse of 20 beats/minute or a systolic drop of 10 to 20 mm Hg is a positive indicator of occult blood loss. Some experts say a drop in systolic blood pressure of 25 mm Hg or a drop in diastolic of 10 mm Hg is positive. Option C has both of these present. The other options don’t represent positive orthostatics.

Nursing process step: Evaluation

Correct answer-C. Rationales: In acid urine (pH less than 5.5), uric acid crystals precipitate, leading to stone formation. Magnesium, ammonia, and phosphate stones (also called triple phosphate, struvite, or infection stones) develop when the urine pH is higher than 7.2 and ammonia is present in the urine. Calcium oxalate stones develop in acid urine (pH less than 6.0). Calcium phosphate stones develop in alkaline urine (pH greater than 7.2).

Nursing process step: Analysis

Correct answer-D. Rationales: An ovarian cyst can cause adhesions and peritonitis from leakage of cystic contents. An ovary can become ischemic from torsion that occurs when a cyst is twisted on its pedicle. Mittelschmerz occurs in the form of abdominal pain at ovulation; it needs to be considered in the differential diagnosis of an ovarian cyst.