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 ["B","D"]
Explanation
Choice A rationale
Scheduled times for dressing changes are not typically included in transfer documentation. This information is usually part of the patient’s daily care plan and can be communicated to the receiving unit as needed.
Choice B rationale
The primary health problem is crucial information to include in the transfer documentation. It provides the receiving unit with a clear understanding of the patient’s main health issue and the reason for their transfer.
Choice C rationale
Admission vital signs from 1 week ago are not typically included in transfer documentation. The most recent vital signs are more relevant and provide a better indication of the patient’s current health status.
Choice D rationale
Current medication prescriptions are essential to include in the transfer documentation. This information ensures continuity of care and prevents medication errors.
Choice E rationale
The number of family members who have visited is not typically included in transfer documentation. This information is not directly related to the patient’s health status or care needs.
Correct Answer is D
Explanation
Choice A rationale
Elevating the head of the bed 45 degrees before starting the CPM device is not necessary. The position of the bed does not affect the operation of the CPM device.
Choice B rationale
Instructing the patient to increase the degree of flexion as tolerated is not the nurse’s responsibility. The degree of flexion is usually set by the healthcare provider or physical therapist.
Choice C rationale
Ensuring the frame joint is in a flexed position before placing the leg onto the device is not necessary. The CPM device should be set up according to the manufacturer’s instructions and the healthcare provider’s orders.
Choice D rationale
Ensuring the knee joint is positioned over the CPM device frame joint is crucial. Proper alignment of the patient’s knee joint with the CPM device’s joint ensures effective and safe operation of the device.
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