An older adult client is brought to the clinic for Increased confusion over the past three days and presents with a draining wound on the right leg. Which assessment is most important for the nurse to obtain?

24-hour medication history.

Amount of serous drainage from the wound.

Urinary output for past six hours.

White blood cell count.

Answer and Explanation

The Correct Answer is D

A. While the medication history can be relevant, it is not the most immediate assessment needed to address the confusion and possible infection.

B. The amount of serous drainage is important for wound assessment but does not directly address the cause of confusion.

C. Urinary output is useful for evaluating kidney function but may not be directly related to the client’s confusion and wound.

D. The white blood cell count is crucial for identifying an infection or inflammatory response, which could be related to both the confusion and the wound.

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Correct Answer is D

Explanation

A. Pain management is important but should follow the assessment of any immediate complications.

B. Ambulation teaching is important but is not the first priority immediately after cast application.

C. Leg elevation can help with swelling but is not the immediate priority.

D. Neurovascular checks are crucial to assess for complications such as compartment syndrome, which can occur after cast application. Early detection of neurovascular impairment is essential to prevent long-term damage.

A. Increased fatigue. B. Watery diarrhea. C. Nausea and headache. D. Yellow-tinged sputum.

Correct Answer is B

Explanation

A. Increased fatigue is a common side effect of many medications and illnesses but is not as immediately concerning.

B. Watery diarrhea can indicate a serious side effect such as Clostridium difficile-associated diarrhea, which requires prompt medical attention.

C. Nausea and headache are common side effects but are generally not urgent.

D. Yellow-tinged sputum can indicate infection but is not as critical as the potential for a serious gastrointestinal issue.

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An older adult client is brought to the clinic for Increased confusion over the past three days and presents with a draining wound on the right leg. Which assessment is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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