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A nurse in a health clinic is caring for a client. Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Nurse's Notes

0930:

  • Client reports 2-day history of urinary frequency, burning on urination, and lower back and suprapubic pain. States developed a fever of 39.3°C (102.8°F) this morning.
  • Oriented x-4, answers questions appropriately.
  • S1, S2, on auscultation. Lungs clear on auscultation.
  • Bowel sounds x 4 quadrants active, denies nausea or vomiting.

0945:

  • Request client provide clean-catch urinary specimen for testing.
  • Urinalysis results reviewed.

Vital Signs 0930:

  • Temperature: 39.3°C (102.8°F)
  • Heart rate: 113/min
  • Respiratory rate: 24/min
  • Blood pressure: 122/68 mm Hg
  • Oxygen saturation: 96% on room air

Diagnostic Results 1030:

Urinalysis

  • Appearance: Cloudy
  • Color: Amber yellow
  • Odor: Aromatic
  • pH: 8.0 (Reference: 4.6 to 8.0)
  • Protein: 6.5 mg/dL (Reference: 0 to 8 mg/dL)
  • Specific gravity: 1.035 (Reference: 1.005 to 1.030)
  • Leukocyte esterase: Positive
  • Nitrites: Present
  • Ketones: None
  • Bilirubin: None

A.

urinary frequency, burning on urination, and lower back

B.

developed a fever of 39.3°C (102.8°F) this morning

C.

Appearance: Cloudy

D.

pH: 8.0 (Reference: 4.6 to 8.0)

E.

Leukocyte esterase: Positive

F.

Nitrites: Present

G.

Heart rate: 113/min

H.

Respiratory rate: 24/min

I.

Specific gravity: 1.035 (Reference: 1.005 to 1.030)

J.

Blood pressure: 122/68 mm Hg

Answer and Explanation

The Correct Answer is ["A","B","C","E","F"]

Client Symptoms:

  • Urinary Symptoms: The client reports a 2-day history of urinary frequency, burning on urination, and both lower back and suprapubic pain.
  • Fever: The client states they developed a fever this morning.

Urinalysis Results:

  • Appearance: Cloudy urine.
  • Leukocyte Esterase: Positive, indicating the presence of white blood cells.
  • Nitrites: Present, suggesting bacterial infection.

Assessment:

  • These findings strongly suggest a Urinary Tract Infection (UTI). The combination of urinary symptoms, fever, and urinalysis results supports this diagnosis. The nurse should promptly report these findings to the healthcare provider to ensure timely intervention.


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Related Questions

Correct Answer is A

Explanation

Choice A reason:
Delirium is a sudden and acute change in mental status characterized by confusion, disorientation, altered consciousness, and other cognitive disturbances. It has an abrupt onset and is often related to an underlying medical condition, medication, or other factors such as infections or metabolic imbalances.
Choice B reason:
Delirium can indeed affect a client's sleep cycle. It often disrupts sleep patterns and can lead to sleep disturbances
Choice C reason:
Delirium does not have a slow progression. It is typically characterized by a rapid and fluctuating course, and it can develop over hours to days.
Choice D reason:
Delirium does affect a client's perception of their environment. Clients with delirium may experience hallucinations, paranoia, and other alterations in perception. They may be unable to accurately interpret or interact with their surroundings.

Correct Answer is B, C, E, D, A

Explanation

B. Provide adequate lighting to inspect the abdomen: Adequate lighting is important to ensure that the nurse can clearly see and assess the client's abdominal area. This step helps identify any visible abnormalities, such as skin changes, scars, masses, or distention.

C. Listen to the abdominal arteries using the bell of a stethoscope: Listening to the abdominal arteries helps the nurse assess blood flow and detect any abnormal vascular sounds, such as bruits or murmurs. This step provides information about vascular health and potential issues related to blood flow.

E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen: Palpating and locating the liver and spleen borders help assess the size and position of these organs. It can help identify hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen), which could indicate various underlying conditions.

D. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen: Palpating the abdomen for tenderness helps identify areas of discomfort or pain. It can provide information about potential inflammation, organ enlargement, or other sources of discomfort.

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