An older female client who resides at an assisted living facility comes for an annual gynecological visit at the clinic and states she has a burning sensation when urinating. Assessment findings include: blood pressure 128/88 mm Hg, urine negative for bacteria, and ecchymotic areas on both forearms. She reports being sexually active and drinks beer once or twice a month. During this clinic visit, which intervention(s) should the nurse implement? Select all that apply.
Ask the client if someone brought her to the clinic.
Review list of daily medications for aspirin or other anticoagulants.
Question her if she previously or currently uses of any illicit drugs.
Inquire if she is being emotionally or physically abused.
Determine number of sexual partners she has had recently.
Correct Answer : B,D,E
Rationale:
A. Ask the client if someone brought her to the clinic: This may be useful in a general assessment but is not directly relevant to the client's urinary symptoms, bruising, or potential abuse concerns. It does not guide immediate care.
B. Review list of daily medications for aspirin or other anticoagulants: Ecchymoses may indicate increased bleeding risk, especially in older adults on aspirin or anticoagulants. Reviewing medications helps determine if bruising is medication-related or from trauma.
C. Question her if she previously or currently uses any illicit drugs: There’s no clinical indicator pointing toward drug use. This line of questioning may be inappropriate or unnecessary unless other findings support it.
D. Inquire if she is being emotionally or physically abused: Unexplained bruising, especially in older adults, can signal possible abuse. The nurse should screen for abuse sensitively and privately.
E. Determine number of sexual partners she has had recently: Given her report of sexual activity and urinary burning, assessing recent sexual history helps guide further STI screening and urinary symptom evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Prevent injury: In CKD, high phosphate and low calcium levels contribute to bone demineralization, increasing fracture risk. Hypocalcemia can also cause muscle cramps and tetany, making fall prevention and safety a priority.
B. Prevent infection: While infection is a general concern in CKD, these specific lab findings do not indicate immunosuppression. The primary issue here relates to bone health and calcium-phosphate imbalance, not immune function.
C. Protect skin integrity: Skin care is important in CKD, especially with pruritus, but it is not the direct consequence of calcium-phosphate imbalance. The immediate risk related to these values is musculoskeletal, not dermatologic.
D. Manage fluid volume: Fluid volume control is essential in CKD but unrelated to phosphate-calcium shifts. These labs reflect mineral and bone metabolism disturbances, not volume overload or deficit.
Correct Answer is B
Explanation
Rationale:
A. Avoid using cosmetics that block sebaceous glands: This advice is more relevant to preventing acne rather than tinea pedis. Tinea pedis, or athlete's foot, is caused by a fungal infection, not by clogged sebaceous glands.
B. Wear water shoes in the public shower: Tinea pedis is commonly transmitted in moist, communal environments like showers and locker rooms. Wearing protective footwear minimizes contact with contaminated surfaces, helping prevent infection.
C. Do not share a brush or comb with anyone: This applies to the prevention of tinea capitis (fungal scalp infection), not tinea pedis. Hair grooming items are not typically involved in the transmission of athlete’s foot.
D. Use moisturizing creams to retain skin moisture: Fungi thrive in warm, moist environments. Applying moisturizers excessively, especially between the toes, can promote fungal growth rather than prevent it. Dry, clean feet are key to prevention.
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