The nurse is caring for an elderly female client who has an indwelling catheter. Which data in the assessment warrants notification of the health care provider?
Change in mental status
Vital signs: T-98, P- 90, RR- 20, BP-142/88.
Client states, "No discomfort or pain."
Urine is cloudy with sediment
The Correct Answer is A
A. This is a significant finding that warrants immediate notification. Changes in mental status in elderly patients can indicate a variety of issues, including infection (such as a urinary tract infection), dehydration, or other acute illnesses. Given that elderly patients are at higher risk for delirium and other cognitive changes, this finding should be taken seriously.
B. These vital signs are largely within normal limits for an elderly patient. While the blood pressure is on the higher side, the heart rate and respiratory rate are within acceptable ranges. Therefore, this does not warrant immediate notification unless other symptoms are present.
C. This statement is reassuring and suggests that the client is not experiencing complications related to the indwelling catheter, such as infection or obstruction. It does not indicate any need for immediate notification of the provider.
D. Cloudy urine with sediment can be indicative of a urinary tract infection (UTI) or other complications related to the indwelling catheter. While this finding is concerning and may require further evaluation, it is not as urgent as a change in mental status. It should still be reported to the healthcare provider but may not necessitate immediate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This option is not the most relevant for penile cancer detection. While swelling and ulcerated areas may be associated with various conditions affecting the scrotum, they are not specifically indicators of penile cancer. Penile cancer is more typically associated with changes in the penis itself rather than the scrotum.
B. Early signs of penile cancer may include a nodular or wart-like growth on the penis, especially on the glans (head) or shaft. These growths can be painless, making regular self-examination important for early detection. This statement demonstrates an understanding of one of the key indicators of penile cancer.
C. While penile discharge can indicate various conditions, including infections or sexually transmitted diseases, it is not a specific sign of penile cancer. This response does not reflect a direct understanding of the early detection of penile cancer.
D. Pain during urination can be caused by many conditions, such as infections or urinary tract issues, and is not a definitive sign of penile cancer. Additionally, many cases of penile cancer may not present with pain at all, particularly in the early stages.
Correct Answer is B
Explanation
A. CA-125 is primarily associated with ovarian cancer and is not a relevant tumor marker for testicular cancer. Serum ceruloplasmin is a copper-carrying protein that can be elevated in various conditions, but it is not specific for testicular cancer. Therefore, this option is not appropriate.
B. Both hCG and AFP are tumor markers specifically associated with testicular cancer. Elevated levels of these markers can indicate the presence of non-seminomatous testicular tumors. Monitoring these markers is essential for diagnosis, assessing treatment response, and detecting recurrence.
C. EPO is involved in red blood cell production and is not a tumor marker for testicular cancer. CEA is primarily associated with colorectal cancer and some other malignancies, but it is not specific for testicular cancer.
D. PSA is a tumor marker associated with prostate cancer, not testicular cancer. While hCG is relevant for testicular cancer, the inclusion of PSA makes this option inappropriate for a client with testicular cancer.
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