A nurse is collecting data from an older adult client who has cystitis. Which of the following findings should the nurse anticipate?
Hypothermia
Referred pain in the right shoulder
Confusion
Orange-colored urine
The Correct Answer is C
Choice c: Confusion is a finding that the nurse should anticipate in an older adult client who has cystitis, which is inflammation of the bladder caused by a bacterial infection. Confusion can be a sign of sepsis or delirium, which are common complications of urinary tract infections in older adults.
Choice a is not correct because hypothermia is not a finding that the nurse should anticipate in an older adult client who has cystitis. Hypothermia can occur in older adults due to impaired thermoregulation, but it is not related to cystitis.
Choice b is not correct because referred pain in the right shoulder is not a finding that the nurse should anticipate in an older adult client who has cystitis. Referred pain in the right shoulder can indicate gallbladder disease, but it is not related to cystitis.
Choice d is not correct because orange-colored urine is not a finding that the nurse should anticipate in an older adult client who has cystitis. Orange-colored urine can be caused by certain medications, foods, or dehydration, but it is not related to cystitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Performing breast exams every other month is not an adequate frequency, as it can delay the detection of any changes or abnormalities. The client should perform breast exams monthly, preferably a few days after their period ends.
Choice B reason: Having one breast larger than the other is a common variation and not a cause for concern, unless there is a sudden change in size or shape. The client should be aware of their normal breast appearance and report any changes to their provider.
Choice C reason: Performing breast exams the day their period begins is not an optimal time, as their breasts may be swollen, tender, or lumpy due to hormonal fluctuations. The client should perform breast exams when their breasts are not affected by their menstrual cycle, such as a week after their period ends.
Choice D reason: Having skin dimpling on their breasts is not a common variation and may indicate an underlying tumor that pulls on the connective tissue and causes puckering of the skin. The client should inspect their breasts for any changes in skin texture, such as dimpling, peau d'orange, or redness, and report them to their provider.
Correct Answer is B
Explanation
Choice A reason: Keeping both arms below the level of the client's heart can increase venous pressure and fluid accumulation in the affected arm, which can lead to lymphedema.
Choice B reason: After a mastectomy, it’s important to avoid procedures like blood draws, injections, or blood pressure measurements on the side where the surgery was performed to prevent lymphedema. Therefore, using the client’s left arm for blood samples is a preventive measure.
Choice C reason: Obtaining blood pressure readings using the client's right arm is an incorrect action that can increase lymphatic fluid accumulation and impair circulation in the affected arm.
Choice D reason: Limiting range-of-motion exercises with the affected arm is an incorrect action that can decrease lymphatic drainage and increase swelling in the affected arm. The nurse should encourage the client to perform gentle exercises, such as squeezing a soft ball or raising and lowering the arm, to promote lymphatic flow and prevent stiffness.
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