The nurse is caring for an elderly female client who has an indwelling catheter. Which data in the assessment warrants notification of the health care provider?
Change in mental status
Vital signs: T-98, P- 90, RR- 20, BP-142/88.
Client states, "No discomfort or pain."
Urine is cloudy with sediment
The Correct Answer is A
A. This is a significant finding that warrants immediate notification. Changes in mental status in elderly patients can indicate a variety of issues, including infection (such as a urinary tract infection), dehydration, or other acute illnesses. Given that elderly patients are at higher risk for delirium and other cognitive changes, this finding should be taken seriously.
B. These vital signs are largely within normal limits for an elderly patient. While the blood pressure is on the higher side, the heart rate and respiratory rate are within acceptable ranges. Therefore, this does not warrant immediate notification unless other symptoms are present.
C. This statement is reassuring and suggests that the client is not experiencing complications related to the indwelling catheter, such as infection or obstruction. It does not indicate any need for immediate notification of the provider.
D. Cloudy urine with sediment can be indicative of a urinary tract infection (UTI) or other complications related to the indwelling catheter. While this finding is concerning and may require further evaluation, it is not as urgent as a change in mental status. It should still be reported to the healthcare provider but may not necessitate immediate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["7"]
Explanation
(desired dose * volume of solution) / (concentration of drug * time) = rate.
For an infusion of 7 units per hour with a concentration of 100 units in 100 mL, the calculation would be: (7 units/hour * 100 mL) / (100 units * 1 hour) = 7 mL/hour.
Therefore, the nurse should set the IV pump to 7 mL per hour to deliver a continuous infusion of insulin at the prescribed rate.
Correct Answer is C
Explanation
A. An ischemic stroke occurs when a blood vessel supplying blood to the brain is obstructed. Common symptoms include sudden numbness or weakness in the face, arm, or leg, confusion, difficulty speaking, and visual disturbances. However, "thunderclap" headache and neck stiffness are not typical symptoms of an ischemic stroke.
B. A TIA, often referred to as a "mini-stroke," produces similar symptoms to a stroke but lasts for a short duration (typically less than 24 hours) and does not cause permanent damage. Symptoms can include weakness, speech difficulties, and visual changes, but again, "thunderclap" headache and neck stiffness are not characteristic of a TIA.
C. A subarachnoid hemorrhage occurs when there is bleeding into the space between the brain and the tissues covering it, often due to a ruptured aneurysm. A "thunderclap" headache, described as an extremely sudden and severe headache, is a hallmark of this condition.
D. A cardioembolic stroke is a type of ischemic stroke that occurs when a blood clot forms in the heart and travels to the brain. Symptoms are similar to those of an ischemic stroke and do not typically include a "thunderclap" headache or neck stiffness.
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