A nurse is assessing an older adult client who has a urinary tract infection (UTI). Which of the following findings should the nurse identify as unique for this age group?
Incontinence
Low back pain
Confusion
Urinary retention
The Correct Answer is C
A. Incontinence: Incontinence can occur in older adults with UTIs, but it is not necessarily unique to this age group and can occur in individuals of all ages with UTIs.
B. Low back pain: Low back pain can be a symptom of a UTI in individuals of any age and is not specifically unique to older adults.
C. Confusion: Confusion, also known as acute delirium, is a common and often unique symptom of UTIs in older adults. It can manifest as disorientation, altered mental status, agitation, or
behavioral changes.
D. Urinary retention: Urinary retention, the inability to completely empty the bladder, is not typically associated with UTIs. It is more commonly seen in conditions such as urinary tract obstruction or neurological disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pupil size and reaction: Pupil size and reaction are typically assessed to monitor neurological function and are not directly related to tissue integrity.
B. Heart rate and blood pressure: Heart rate and blood pressure are vital signs that provide information about cardiovascular function but do not specifically assess tissue integrity.
C. Respiratory rate and oxygen saturation: Respiratory rate and oxygen saturation are indicators of respiratory function and oxygenation status and are not directly related to tissue integrity.
D. Skin turgor and moisture: Skin turgor, the skin's ability to return to its normal shape after being pinched, and moisture levels are important assessments for monitoring tissue hydration and integrity. Changes in skin turgor and moisture can indicate dehydration, which can impair tissue integrity and wound healing.
Correct Answer is B
Explanation
A. Implement neutropenia isolation: Neutropenia isolation is not applicable for a client with C. diff infection. Neutropenia isolation is used for clients with low neutrophil counts to protect them from exposure to pathogens due to their compromised immune system.
B. Disinfect equipment with bleach solution: Clostridium difficile spores are resistant to many disinfectants, but they can be effectively killed by bleach solutions (sodium hypochlorite).
Disinfecting equipment with bleach solution helps prevent the spread of C. diff infection.
C. Monitor the client for manifestations of fluid overload: Manifestations of fluid overload, such as edema or shortness of breath, are not typically associated with C. diff infection. Monitoring for fluid overload is important in other clinical contexts, such as heart failure.
D. Use alcohol hand sanitizer following client care: Alcohol-based hand sanitizers are not effective against C. diff spores. Hand hygiene should be performed with soap and water, as alcohol-based sanitizers are not effective against C. diff spores.
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