When planning care for a client with right ureteral renal calculi, which of the following nursing diagnosis has the less priority of care while caring for this patient?

Impaired urinary elimination related to obstructed flow of urine.

Acute pain related to obstruction by the stone.

Risk for urinary sepsis related to urinary stasis.

Deficient knowledge related to need for prevention of recurrence of calculi.

Answer and Explanation

The Correct Answer is D

Choice A rationale: Addressing the obstruction and restoring urinary flow is a priority to prevent complications.

Choice B rationale: Managing pain caused by the stone obstruction is essential for the client's comfort and well-being.

Choice C rationale: Preventing urinary stasis and subsequent infection is crucial to avoid sepsis.

Choice D rationale: Education about prevention, though important, might have a lower priority compared to addressing immediate complications like obstruction and pain.

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Correct Answer is C

Explanation

Choice A rationale: Performing active range of motion exercises may not be safe or appropriate immediately following a hemorrhagic stroke.

Choice B rationale: Maintaining the head of bed flat or at a 30-degree position might be used for ischemic strokes but not necessarily for hemorrhagic strokes.

Choice C rationale: Teaching measures to avoid the Valsalva maneuver (straining during activities like defecation) helps prevent sudden increases in intracranial pressure, which can be detrimental after a hemorrhagic stroke.

Choice D rationale: Monitoring for Battle's sign (bruising behind the ears associated with basilar skull fracture) is not relevant in the care of a hemorrhagic stroke.

A. Altered level of consciousness B. The onset of symptoms is months to years C. Progressively worsens D. May be caused by fluid and electrolyte imbalances or infection E. May be caused by uncontrolled hypertension and diabetes F. May cause impairments in judgment G. Memory impairments

Correct Answer is ["A","D","F"]

Explanation

Choice A rationale: Altered consciousness is a hallmark feature of delirium, where individuals may experience fluctuations in awareness.

Choice B rationale: Delirium typically has an acute onset rather than symptoms developing over months to years.

Choice C rationale: Delirium often has a fluctuating course, rather than a consistent progressive decline.

Choice D rationale: Delirium can result from various factors including fluid/electrolyte imbalances or infections.

Choice E rationale: While these conditions might contribute to cognitive impairments, they are not typically associated with delirium.

Choice F rationale: Delirium can affect judgment, but it's not a defining feature.

Choice G rationale: While memory impairments can be seen in delirium, they're often accompanied by altered consciousness and fluctuations in awareness.

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When planning care for a client with right ureteral renal calculi, which of the following nursing diagnosis has the less priority of care while caring for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care?

Correct Answer is C

Explanation

A client arrives at the clinic with his daughter, reporting memory impairments: Exhibits Which of the following clinical feature are consistent with delirium? Select all that apply?

Correct Answer is ["A","D","F"]

Explanation

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