A nurse is collecting data from an older adult client.Which of the following findings should the nurse identify as indicating the client has a bladder infection?

Changed mental status.

WBC Count 9,000/mm³ (5,000 to 10,000/mm³).

Diminished reflexes.

Temperature 37.3°C (99.1°F).

Answer and Explanation

The Correct Answer is A

Choice A rationale

A changed mental status is a common sign of a urinary tract infection, especially in older adults, due to the effects of the infection on the central nervous system.

Choice B rationale

WBC count 9,000/mm³ is within the normal range of 5,000 to 10,000/mm³ and does not indicate an infection on its own.

Choice C rationale

Diminished reflexes are not typically associated with bladder infections and are not a reliable indicator.

Choice D rationale

A temperature of 37.3°C (99.1°F) is within the normal range and does not necessarily indicate a bladder infection.

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Correct Answer is A

Explanation

Choice A rationale

Placing the client in a private room with a private bathroom helps prevent the spread of the infection to other patients and ensures that the client’s wound drainage, which is likely contagious, does not contaminate shared facilities. This isolation measure is crucial in managing infectious wounds.

Choice B rationale

Discarding soiled wound care supplies outside the client's room increases the risk of contaminating common areas. Proper disposal of contaminated materials within the room is necessary to contain the infection.

Choice C rationale

Instructing visitors to perform hand hygiene for only 5 seconds is insufficient. Proper hand hygiene requires at least 20 seconds of scrubbing with soap and water or an alcohol-based hand sanitizer to effectively remove pathogens.

Choice D rationale

Administering antibiotic therapy before culturing the client's wound could interfere with the accuracy of the culture results. Cultures should be obtained before starting antibiotic therapy to identify the causative organism accurately.

A. Encourage the client to use a straw. B. Provide oral care before meals. C. Schedule physical therapy directly before meals. D. Instruct the client to tilt their head back to facilitate swallowing.

Correct Answer is B

Explanation

Choice A rationale

Using a straw can increase the risk of aspiration in clients with dysphagia as it forces liquid directly to the back of the throat without adequate control.

Choice B rationale

Providing oral care before meals can help stimulate the appetite and ensure that the mouth is clean, reducing the risk of infection and improving the overall eating experience.

Choice C rationale

Scheduling physical therapy directly before meals can cause fatigue, making it more difficult for the client to eat safely and effectively.

Choice D rationale

Tilting the head back can increase the risk of aspiration. The safer method for clients with dysphagia is usually to keep the head in a neutral or slightly forward position when swallowing.

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A nurse is collecting data from an older adult client.Which of the following findings should the nurse identify as indicating the client has a bladder infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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