The nurse is caring for an 84-year-old female client who was brought to the emergency room by her daughter, who related that her mother has had very recent mental status changes and periods of incontinence. What condition should the nurse first suspect?

Urinary tract infection

Acute kidney failure

Septic shock

Urinary stasis

Answer and Explanation

The Correct Answer is A

A. Urinary tract infection
The symptoms described, including recent mental status changes and periods of incontinence, are suggestive of a urinary tract infection (UTI) in an elderly individual. UTIs are common among older adults and can cause a variety of symptoms, including confusion, which is often the primary manifestation in the elderly population. Other symptoms can include urinary urgency, frequency, and incontinence.

B. Acute kidney failure - While acute kidney failure can cause changes in urination and mental status, it is less likely to be the primary cause of these symptoms in this scenario. UTI is a more common and immediate concern given the symptoms described.

C. Septic shock - Septic shock is a severe condition that occurs when an infection leads to a life-threatening drop in blood pressure. While septic shock can cause altered mental status, it is a critical condition that often presents with more dramatic symptoms and requires immediate intensive care management. The symptoms described are more suggestive of a UTI.

D. Urinary stasis - Urinary stasis refers to the slowing or cessation of urine flow. While urinary stasis can contribute to the development of UTIs, it is not a condition that would cause sudden and acute mental status changes and incontinence on its own. UTI is a more likely cause of the symptoms described.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Remove heel boots:
Heel boots are often used to protect the heels from pressure ulcers. However, it's important to assess the skin regularly and remove heel boots periodically to inspect the skin underneath. Leaving them on continuously without proper inspection can cause moisture buildup, leading to skin breakdown.

B. Reposition every 3 hours
Repositioning the client every 3 hours is a crucial intervention to prevent skin breakdown, especially in individuals at risk, such as older adults. Prolonged pressure on specific areas of the body can lead to pressure ulcers or bedsores. Regular repositioning helps relieve pressure on vulnerable areas, improving circulation and reducing the risk of skin breakdown.

C. Apply cornstarch to keep the skin dry:
While it's essential to keep the skin clean and dry, using cornstarch can sometimes lead to moisture retention, especially in skin folds. Excess moisture can contribute to skin breakdown and fungal infections. Instead, proper hygiene practices and the use of moisture-wicking products are recommended.

D. Provide high protein diet:
Adequate nutrition, including a high-protein diet, is essential for overall skin health and healing. Protein is necessary for tissue repair and regeneration. While a balanced diet is crucial for overall health, it is not a specific intervention solely focused on maintaining skin integrity.

A. "You will need to lie flat for 4 hours following the test." B. "You will need to empty your bladder before the test." C. "You will need to have an IV inserted for the IV dye needed for the scan." D. "You will need to fast for 12 hours before the test."

Correct Answer is B

Explanation

A. There is no need for the client to lie flat for an extended period after a DEXA scan. The procedure is non-invasive and does not require immobilization.

B. Emptying the bladder before the test is essential to ensure a clear and accurate scan of the pelvis and lower spine. A full bladder might obstruct the view and affect the accuracy of the results.

C. DEXA scans do not typically require the use of IV dye. It is a simple X-ray procedure that measures bone density, and no contrast material is usually needed.

D. Fasting is not necessary for a DEXA scan. The procedure does not involve ingesting or injecting any substances that require fasting.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for an 84-year-old female client who was brought to the emergency room by her daughter, who related that her mother has had very recent mental status changes and periods of incontinence. What condition should the nurse first suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is A

Explanation

A nurse is teaching a client who is scheduled for dual-energy x-ray absorptiometry (DEXA) to screen for osteoporosis. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?

A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults, such as thinning skin. How should these students best integrate these changes into care planning?

A nurse is teaching a lactose intolerant client at high risk for osteoporosis about dietary measures she can take to increase her calcium level. Which of the following foods should the nurse advise the client to increase in her diet?

A nurse needs to infuse three 1L bags over 12 hours. At what rate should the nurse program the pump to run in millilitres per hour? (Round to the nearest whole number.)

A nurse in a busy emergency department provides care for many clients who present with contusions, strains, or sprains. What are treatment modalities that are common to all of these musculoskeletal injuries? Select all that apply.

A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take?

A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?