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 D
Explanation
A. Increased urinary output: Phenazopyridine (Pyridium) does not directly impact urinary output. Its primary function is to provide relief from urinary pain, burning, and discomfort associated with urinary tract infections (UTIs) or other urinary conditions. It does not affect the amount of urine a person produces.
B. Decreased WBC's: Phenazopyridine does not directly influence white blood cell count (WBCs). WBC count is an indicator of the body's immune response and is typically used to assess the presence of infection. Phenazopyridine provides symptomatic relief but does not affect the underlying infection or the body's immune response to it.
C. Increased uric acid: Phenazopyridine does not affect uric acid levels. Uric acid is a waste product that is excreted by the kidneys. Elevated uric acid levels can be associated with conditions like gout, but Phenazopyridine does not have any direct impact on these levels.
D. Decreased bladder pain/spasms: Phenazopyridine is intended to relieve symptoms such as bladder pain, spasms, burning sensation, and discomfort experienced during urination. Therefore, the effectiveness of Phenazopyridine is indicated by a reduction in these symptoms. If the patient reports a decrease in bladder pain and spasms, it suggests that the medication is working to alleviate the discomfort associated with urinary tract issues.
Correct Answer is C
Explanation
A. Avoiding the use of ice packs to treat muscle pain - While ice packs can cause skin damage in older adults with thinning skin, it is not the most appropriate response to the question. Protecting against shearing injuries is a more direct and specific concern related to thinning skin.
B. Protecting older adults against excessive sweat accumulation - Excessive sweat accumulation can lead to skin irritation, but this option does not directly address the issue of thinning skin as the primary concern in the question.
C. By protecting older adults against shearing injuries
Thinning skin in older adults makes them more vulnerable to skin injuries, especially shearing injuries. Shearing occurs when the skin is pulled in one direction while the underlying bone and tissues are pulled in the opposite direction. This can lead to skin tears and other wounds, which can be painful and slow to heal in older adults. Nurses should take special precautions to prevent shearing injuries, such as using lift sheets or sliding devices when moving patients, and ensuring that patients are repositioned frequently to reduce friction and shearing forces.
D. Avoiding the use of lotion on older adults' skin - Proper moisturization of the skin is important, especially in older adults, to prevent dryness and skin breakdown. Avoiding lotion is not a recommended practice; instead, choosing appropriate, non-irritating lotions can help maintain skin integrity.
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