A nurse is reinforcing bladder management instructions with a client who has urinary incontinence.Which of the following statements by the client indicates an understanding?

 

Choice A rationale

Two servings of fruits and vegetables per day do not provide sufficient phytochemicals, fiber, and antioxidants necessary for effective cancer risk reduction. Current guidelines recommend five or more servings per day for optimal benefit in reducing cancer risk.

Choice B rationale

Red and processed meats contain nitrates and nitrites that can convert into carcinogenic compounds like nitrosamines during digestion. Limiting their intake reduces the exposure to these harmful compounds, thereby lowering the risk of certain cancers, such as colorectal cancer.

Choice C rationale

Whole-grain foods are rich in dietary fiber, which aids in the removal of carcinogens from the gastrointestinal tract. Limiting their intake contradicts guidelines that emphasize increasing whole-grain consumption for cancer prevention and overall health.

Choice D rationale

Fatty fish is rich in omega-3 fatty acids, which have anti-inflammatory properties. However, eating it once per week does not provide sufficient quantities to significantly impact cancer prevention. The recommendation is to consume fatty fish multiple times per week for health benefits.

C. Unable to remember their adult children's names.

D. Unable to answer a judgment task correctly.

Answer and explanation

The correct answer is Choice A.

Choice A rationale

Inability to remain fully awake after head trauma indicates decreased neurological function, a sign of intracranial injury or bleeding, requiring immediate attention. Reduced consciousness compromises airway protection and perfusion. Normal intracranial pressure ranges from 7 to 15 mmHg in adults; elevated levels can indicate pathology. This finding is critical for prioritization to prevent irreversible brain damage.

Choice B rationale

Difficulty repeating named objects suggests short-term memory loss, often linked to conditions like concussion. However, it does not pose an immediate life threat like compromised consciousness does. Neurological evaluation is necessary but secondary in priority unless paired with other severe symptoms like loss of consciousness or seizures.

Choice C rationale

Failure to recall adult children’s names suggests long-term memory impairment. While it may indicate brain injury or dementia exacerbation, it is not an immediate threat compared to decreased alertness. Cognitive decline should be addressed later after stabilizing potential life-threatening conditions.

Choice D rationale

Errors in judgment tasks reflect possible frontal lobe dysfunction or cognitive impairment. Though concerning, this is not the most urgent finding unless associated with symptoms like increased intracranial pressure or stroke. Addressing primary life-sustaining functions remains the priority.