A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

Temperature 37.3° C (99.1° F)

WBC Count 9,000/mm3

Changed mental status

Diminished reflexes

Answer and Explanation

The Correct Answer is C

A bladder infection can lead to confusion or other changes in mental status, especially in older adults. A normal temperature and WBC count do not necessarily indicate a bladder infection. Diminished reflexes are not typically associated with a bladder infection.

A: A temperature of 37.3° C (99.1° F) is within the normal range and does not necessarily indicate a bladder infection.

B: A WBC count of 9,000/mm3 is within the normal range and does not necessarily indicate a bladder infection.

D: Diminished reflexes are not typically associated with a bladder infection.

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Correct Answer is A

Explanation

The nurse should include monitoring for muscle paralysis in the plan of care for a client with botulism poisoning. Botulism is a serious bacterial illness that can cause muscle paralysis and can be life threatening. Monitoring for muscle paralysis is essential for early detection and intervention.

Choice B is incorrect because contact isolation is not necessary for the treatment of botulism.

Choice C is incorrect because increased salivation is not a common symptom of botulism.

Choice D is incorrect because clindamycin hydrochloride is not used to treat botulism.

A. Obtain a set of vital signs. B. Flex the client's knees and hips. C. Apply a moist saline dressing to the area. D. Elevate the head of the client's bed 20°.

Correct Answer is C

Explanation

The correct answer is c. Apply a moist saline dressing to the area.

Choice A reason: Obtaining a set of vital signs is important, but it is not the immediate priority in this situation. The vital signs will not address the protruding organs directly.

Choice B reason: Flexing the client’s knees and hips may provide comfort but does not directly address the issue of the open incision and protruding organs.

Choice C reason: Applying a moist saline dressing to the area is the correct action. It helps to protect the protruding organs by keeping them moist and reduces the risk of organ damage or infection. This is the priority action to keep the organs moist and reduce the risk of tissue damage until surgical repair can be done.

Choice D reason: Elevating the head of the client’s bed 20° may be part of the overall care plan, but it is not the immediate priority when dealing with protruding organs from an open abdominal incision.

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A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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