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 {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices
- Quality of life: Quality of life encompasses the client’s emotional well-being, ability to engage in meaningful activities, and overall life satisfaction. Since the client expressed distress over social isolation and being restricted from activities she previously enjoyed, assessing this domain is essential to determine the impact of the intervention.
- Functional improvement: The client previously reported being active and independent. Monitoring progress in strength, mobility, and independence in ADLs—especially with the addition of physical and occupational therapy—is crucial for measuring the effectiveness of care and promoting client autonomy.
Rationale for Incorrect Choices
- Financial security: There are no concerns or reports related to the client’s access to funds, misuse of money, or financial stress. The care plan and outcomes are not centered around her financial state.
- Cognitive status: Although the client has early-stage dementia, she is currently alert, oriented, and capable of participating in discussions. The interventions aim to improve physical function and well-being rather than targeting cognitive decline at this stage.
- Psychological assessment: The scenario does not describe symptoms of depression, anxiety, or emotional distress requiring formal psychological evaluation. The focus is more on restoring physical function and improving day-to-day satisfaction.
Correct Answer is ["C","E","F","H"]
Explanation
Rationale:
A. Respiratory Therapist: Although respiratory therapists are involved when respiratory compromise occurs, the client has normal oxygen saturation and stable respiratory function, so this role isn’t prioritized in current care.
B. Pharmacy Technician: Pharmacy technicians focus on medication dispensing and inventory, but do not participate in direct patient care or individualized therapy planning for stroke recovery.
C. Speech Therapist: A speech therapist is essential for evaluating and managing post-stroke speech and swallowing difficulties, such as dysarthria and dysphagia, which this client is exhibiting.
D. Medical Assistant: Medical assistants support clinic operations and perform basic administrative or procedural tasks, not advanced rehabilitative or discharge planning roles in acute stroke recovery.
E. Case Manager: The case manager facilitates discharge planning, ensures access to follow-up care and services, and coordinates rehabilitation or home care as needed for stroke recovery.
F. Physical Therapist: A physical therapist aids in improving mobility and strength, especially with the client’s observed diminished left-sided motor function, helping restore independence and prevent complications.
G. Chief Nursing Officer: The CNO is a high-level administrative leader not involved in direct bedside care or individual rehabilitation planning, making them unnecessary for the client’s interdisciplinary recovery team.
H. Occupational Therapist: Occupational therapists help the client regain skills needed for daily living, such as dressing or feeding, which may be impaired due to hemiparesis from the stroke.
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