A nurse is gathering data from an older adult client.
Which finding should alert the nurse to a potential bladder infection?
Diminished reflexes
WBC count 900/mm^3 (normal range: 5000 to 16,000/mm^3)
Temperature 33.9°C
Altered mental status
The Correct Answer is D
Choice D.
Choice A rationale
Diminished reflexes are a common finding in older adults due to the natural aging process of the nervous system and do not necessarily indicate a bladder infection.
Choice B rationale
A WBC count of 900/mm^3 is significantly lower than the normal range of 5000 to 16,000/mm^33. While this could indicate an issue with the immune system, it does not specifically point to a bladder infection.
Choice C rationale
A temperature of 33.9°C is lower than the average body temperature and does not suggest a bladder infection. Fever is a common symptom of infection, but hypothermia is not.
Choice D rationale
Altered mental status in an older adult client can be a sign of a urinary tract infection (UTI), including a bladder infection. UTIs in older adults can present with non-specific symptoms such as changes in mental status, making them harder to diagnose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Loosening the screws while cleaning the pin sites is not recommended. The screws are tightened to a specific pressure to ensure the halo vest is secure and provides the necessary immobilization.
Choice B rationale
The nurse should also provide education regarding changing positions at least every 2 hours to reduce pressure injuries.
Choice C rationale
Halo-vests are managed and monitored during spinal outpatient clinics and can be removed during this clinic appointment.
Choice D rationale
The halo ring should never be used to lift or reposition the client because it is directly attached to the skull. Pulling on the ring could cause serious injury or dislocation.
Correct Answer is ["1.5"]
Explanation
Step 1: Identify the order. The order is for 15,000 units of heparin.
Step 2: Identify the available medication. The available medication is heparin 10,000 units/mL.
Step 3: Calculate the dose. To find out how many mL to administer, divide the number of units ordered by the number of units per mL. So, 15,000 units ÷ 10,000 units/mL = 1.5 mL. So, the nurse should administer 1.5 mL of heparin with each dose.
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