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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Provide regular oral care for the client with a moist swab. When a client with a terminal illness and in the active phase of dying refuses further hydration and nourishment, the nurse should provide comfort measures such as regular oral care to prevent discomfort. The nurse should not force the client to eat or drink or request a prescription for IV fluids. The healthcare surrogate cannot be asked for permission to withhold nourishment as the client has the right to refuse nourishment.
Option A - The client has the right to refuse nourishment, and healthcare surrogate permission is not required.
Option B - Requesting a prescription for IV fluids is not an appropriate intervention as the client has the right to refuse nourishment.
Option C - Explaining the importance of oral hydration to the client is not an appropriate intervention as the client has the right to refuse nourishment.
Correct Answer is B
Explanation
The correct answer is choice B, a client who had abdominal surgery 2 days ago and the incision line is separating. This client requires immediate attention as a separating incision can indicate wound dehiscence or evisceration, which are surgical emergencies. Choice A is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention. Choice C is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition. Choice D is incorrect because the client fell 12 hours ago and reports pain as 4 on a scale of 0 to 10, which indicates a low level of pain.
Choice A: A client who has Clostridium difficile and has liquid stools is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention.
Choice C: A client who has a chronic tracheostomy and is intermittently coughing up clear sputum is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition.
Choice D: A client who fell 12 hours ago and reports pain as 4 on a scale of 0 to 10 is incorrect because the level of pain is low and does not require immediate attention.
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