The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Answer: B. Wandering behavior with flat affect.

Rationale:

A. Ambulatory and disoriented to place:
This documentation suggests that the client is physically able to walk but does not adequately capture the behavioral aspect of the observation. While the client may be ambulatory, merely stating disorientation does not convey the lack of engagement or emotional response, which is crucial in understanding the client's mental state and overall condition.

B. Wandering behavior with flat affect:
This option accurately reflects the observed behavior of the client. "Wandering behavior" captures the aimless walking, while "flat affect" describes the lack of emotional expression indicated by the blank stare. This documentation provides a clearer picture of the client's mental status, which is vital for further assessment and intervention.

C. Appears confused and depressed:
While confusion may be a relevant aspect of the client's condition, this statement lacks specificity regarding the observed behaviors. Depression cannot be accurately concluded from the blank expression alone, as it may not reflect sadness or mood but rather a cognitive or perceptual issue. More objective descriptors would enhance the clarity of the documentation.

D. Demonstrates signs of early dementia:
This option makes a definitive statement about the possibility of early dementia without sufficient evidence from the observation. While aimless walking and a blank expression can be associated with cognitive decline, diagnosing dementia requires comprehensive assessment and evaluation beyond a single observation. This phrasing could mislead healthcare providers regarding the client’s condition and may lead to premature conclusions about the client’s cognitive health.

A) Use a doppler to assess an audible DP pulse:
Using a doppler to assess an audible DP pulse may provide additional information about the presence or absence of the pulse, but it does not address the underlying cause of the absent pulse. It is important to first investigate potential causes, such as vascular disease, before resorting to additional assessment techniques.

B) Place a mark where DP pulse is auscultated:
Marking the location where the DP pulse is auscultated may assist with future assessments but does not address the underlying reason for the absent pulse. It is essential to determine the cause of the absent pulse before considering further interventions.

C) Review client's history for vascular disease:
Reviewing the client's history for vascular disease is the most important intervention in this scenario. Absence of a DP pulse may indicate peripheral vascular disease or other circulatory issues. Reviewing the client's history for risk factors such as diabetes, hypertension, smoking, or previous vascular problems can provide valuable information to guide further assessment and management.

D) Assess capillary refill distal to the DP pulse:
Assessing capillary refill distal to the DP pulse is important for evaluating peripheral perfusion but may not directly address the underlying cause of the absent pulse. While assessing capillary refill is a valuable assessment, reviewing the client's history for vascular disease takes precedence in determining the cause of the absent DP pulse.