The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?

Straining on urination and nocturia

Azotemia and anorexia.

Hematuria and proteinuria.

Fever and dysuria.

Answer and Explanation

The Correct Answer is D

A.   These symptoms indicate a urinary tract issue but do not necessarily indicate a high risk for injury. While they are uncomfortable, they do not typically lead to physical harm.
B.   Azotemia is the build-up of waste products in the blood, and anorexia is a loss of appetite. These symptoms indicate a more severe kidney problem and do not specifically point to an increased risk of injury due to a potential UTI.
C.   These symptoms suggest kidney involvement but do not necessarily indicate an imminent risk of injury. While they are important to address, they do not warrant the nursing problem of "high risk for injury due to potential urinary tract infection."

D.   Fever and dysuria are classic symptoms of a urinary tract infection (UTI). A UTI can progress to a more serious infection, such as pyelonephritis, which can lead to sepsis and potentially life-threatening complications. Therefore, these symptoms indicate a high risk for injury due to the potential for a UTI to worsen.

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Correct Answer is A

Explanation

A. Vital signs are critical for assessing the client’s current hemodynamic status. Coffee-ground emesis can indicate gastrointestinal bleeding, which might lead to complications like hypovolemia or shock.

Vital signs can provide essential information about the client’s condition and help determine the urgency of intervention. Checking vital signs is a priority in assessing the severity of the situation and guiding further actions.
B. Measuring abdominal girth is useful in assessing for abdominal distention or fluid accumulation, which can be relevant in some gastrointestinal conditions. However, in the immediate context of coffee- ground emesis, the most urgent concern is evaluating the client's hemodynamic stability rather than focusing on abdominal girth.
C. Flushing of the skin might be relevant in certain contexts (e.g., reactions to medications or infections), but it is not directly related to the immediate concern of gastrointestinal bleeding and the client’s hemodynamic status. It is less critical compared to assessing vital signs in this situation.
D. While auscultating breath sounds is important for evaluating respiratory status and detecting any pulmonary complications, it is not the immediate priority in the context of coffee-ground emesis. The primary concern should be assessing for signs of hemodynamic instability that may result from gastrointestinal bleeding.

A. Teach about compliance to reduce blood pressure. B. Provide rest periods and portable oxygen. C. Maintain continuous monitoring of heart rate and rhythm. D. Administer nitroglycerin daily.

Correct Answer is A

Explanation

A. This is the most likely intervention to avert cardiomegaly and improve myocardial contractility. By reducing blood pressure, the heart doesn't have to work as hard to pump blood, which can help prevent the heart from enlarging (cardiomegaly) and improve its ability to contract effectively.
B. While rest and oxygen can help manage symptoms of heart failure, they do not directly address the underlying issue of increased cardiac workload and hypertrophy.
C. Monitoring heart rate and rhythm is important for assessing the patient's condition, but it does not prevent cardiomegaly or improve contractility.
D. Nitroglycerin is used to treat acute symptoms of heart failure, such as chest pain, but it is not a long- term solution for preventing cardiomegaly or improving contractility.

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