The nurse is assessing a client admitted with renal stones. During the admission assessment, what is the priority questions to ask?
Recent travel
Typical diet and fluid intake history
Vaccination records
Last bowel movement
The Correct Answer is B
A. Recent travel: Assessing recent travel history is relevant in understanding potential exposure to certain infections or dietary habits specific to certain regions. However, for a client admitted with renal stones, the immediate focus is on understanding factors related to their condition. While travel history might be a part of the overall assessment, it is not the priority question in this context.
B. Typical diet and fluid intake history: This is the priority question. Understanding the client's typical diet, including the types of foods they consume and their fluid intake habits, is crucial. Certain dietary factors, such as high intake of oxalate-rich foods or insufficient fluid intake, can contribute to the formation of renal stones. Gathering this information helps healthcare providers identify potential dietary factors that might have led to the stones, allowing for tailored dietary recommendations and prevention strategies.
C. Vaccination records: Vaccination records are essential for preventive healthcare, but they are not directly related to the assessment of a client admitted with renal stones. While ensuring clients are up-to-date with vaccinations is important, it is not the immediate concern in the context of renal stones.
D. Last bowel movement: Bowel movements are relevant to overall health and can provide information about gastrointestinal function. However, in the specific context of assessing a client admitted with renal stones, understanding the client's bowel movements is not the primary concern. The focus should be on factors directly related to renal stones, such as diet and fluid intake history, which can inform immediate interventions and prevention strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Apply cold compress to the client's flank area - Applying a warm compress, not a cold one, to the flank area can help alleviate pain associated with urolithiasis. Heat can promote muscle relaxation and increase blood flow to the area, potentially easing discomfort.
B. Restrict protein intake to 2 servings per day - There is no direct connection between protein intake and urolithiasis. However, specific dietary recommendations may vary based on the type of kidney stones a person has. For example, individuals with certain types of stones might be advised to limit oxalate-rich foods. It's essential to tailor dietary advice based on the composition of the stones.
C. Encourage intake of at least 3 L of fluids per day - Adequate fluid intake, particularly water, is crucial for preventing the formation of kidney stones. Increased fluid intake can help dilute substances in the urine that contribute to stone formation, reducing the risk of stone recurrence.
D. Discourage ambulation - Encouraging ambulation and movement is generally beneficial for patients with urolithiasis. Movement can help alleviate discomfort, prevent complications such as blood clots, and promote overall well-being. Restricting movement unnecessarily is not advisable.
Correct Answer is ["B","C","D","E"]
Explanation
A. Malunion: Malunion happens when a fractured bone heals in an improper position, leading to deformity and functional impairment. While it is a concern, it typically develops over time during the healing process and is not an immediate early complication that the nurse would monitor for in the acute phase following a fracture.
B. Compartment syndrome: Compartment syndrome is a serious condition that can occur after an injury, such as a fracture. When there is increased pressure within a muscle compartment, it can lead to reduced blood flow, potentially causing tissue damage and nerve injury. Prompt recognition and intervention are crucial to prevent complications.
C. Fat embolism: Fat embolism occurs when fat particles from the bone marrow or other sources enter the bloodstream, often after a long bone fracture or major trauma. These particles can travel to the lungs and other organs, causing respiratory distress, confusion, and other symptoms. Fat embolism is a significant concern in orthopedic trauma patients and requires careful monitoring.
D. Deep vein thrombosis (DVT): DVT is the formation of blood clots in deep veins, usually in the legs. Patients with fractures, especially those immobilized for extended periods, are at increased risk for DVT. If a clot dislodges and travels to the lungs, it can cause a pulmonary embolism, which is a life-threatening complication.
E. Pulmonary emboli: Pulmonary emboli occur when blood clots, often originating from DVT, travel to the lungs and block pulmonary arteries. This condition can lead to sudden difficulty breathing, chest pain, and even cardiac arrest. Pulmonary embolism is a medical emergency and requires immediate intervention.
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