A nurse is gathering data from an older adult client.
Which finding should alert the nurse to a potential bladder infection?
Diminished reflexes
WBC count 900/mm^3 (normal range: 5000 to 16,000/mm^3)
Temperature 33.9°C
Altered mental status
The Correct Answer is D
Choice D.
Choice A rationale
Diminished reflexes are a common finding in older adults due to the natural aging process of the nervous system and do not necessarily indicate a bladder infection.
Choice B rationale
A WBC count of 900/mm^3 is significantly lower than the normal range of 5000 to 16,000/mm^33. While this could indicate an issue with the immune system, it does not specifically point to a bladder infection.
Choice C rationale
A temperature of 33.9°C is lower than the average body temperature and does not suggest a bladder infection. Fever is a common symptom of infection, but hypothermia is not.
Choice D rationale
Altered mental status in an older adult client can be a sign of a urinary tract infection (UTI), including a bladder infection. UTIs in older adults can present with non-specific symptoms such as changes in mental status, making them harder to diagnose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Drinking milk with the medication is not recommended because calcium can bind to alendronate, reducing its absorption.
Choice B rationale
Alendronate should be taken on an empty stomach, at least 30 minutes before the first food, beverage, or other medication of the day.
Choice C rationale
Patients should sit upright for at least 30 minutes after taking alendronate to prevent esophageal irritation.
Choice D rationale
Alendronate tablets should be swallowed whole, not chewed, to prevent oropharyngeal ulceration.
Correct Answer is B
Explanation
Choice A rationale
While it’s true that there are other ways to express intimacy besides intercourse, this response may not address the patient’s specific concern about sexual function following an orchiectomy.
Choice B rationale
This response directly addresses the patient’s concern. The removal of a single testicle does not typically prevent a man from having an erection or enjoying sexual activity.
Choice C rationale
While focusing on recovery is important, this response may not be helpful to the patient. It does not address his concern about sexual function and may make him feel that his concerns are being dismissed.
Choice D rationale
This response may not be helpful to the patient. It does not address his concern about sexual function and may make him feel that his feelings are being minimized.
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