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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Using adaptive equipment suggests they are finding ways to maintain independence and complete activities of daily living (ADLs) despite any physical or cognitive limitations. This is a positive sign of adaptation.
B. Difficulty using modified feeding utensils suggests that the client is struggling to adapt to the changes caused by the stroke. If they cannot use these utensils effectively, it indicates a challenge in managing their eating independently, which is not a sign of successful adaptation.
C. While emotional responses like depression and irritability are common after a stroke, experiencing these feelings frequently can indicate difficulty in coping with the changes. This does not reflect successful adaptation; rather, it suggests that the client may be struggling emotionally and psychologically with their new circumstances.
D. While frustration can be a normal response to challenges after a stroke, particularly in the context of regaining independence, getting angry at family members may indicate difficulty in coping with the changes or an inability to manage frustration.

A. Warfarin B. Simethicone C. Simvastatin D. Enoxaparin

Correct Answer is C

Explanation

A. Warfarin is an anticoagulant used to prevent blood clots. While it may be prescribed for certain patients at risk for stroke, it is not typically the first-line medication for managing TIA or hyperlipidemia. It is more often used in patients with specific types of atrial fibrillation or mechanical heart valves.
B. Simethicone is an anti-foaming agent used to relieve gas and bloating. It does not have any role in managing hyperlipidemia or preventing strokes. Thus, this option is not relevant to the client's condition.
C. Simvastatin is a statin medication used to lower cholesterol levels and reduce the risk of cardiovascular events, including stroke. For a client with hyperlipidemia and a history of TIA, simvastatin would be an appropriate medication to help manage cholesterol and decrease the risk of future ischemic events.
D. Enoxaparin is a low-molecular-weight heparin used for anticoagulation, often in the context of deep vein thrombosis or pulmonary embolism. It may not be the first choice for TIA management. While it has its uses in preventing clot formation, it is not the standard treatment for a patient who has had a TIA.

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Blood Cell	Normal Ranges
Red blood cells (mature, circulating)	Male 4.51-6.01 million/mm3 Female: 4.01-5.51 million/mm3
Hemoglobin	Adult (15-64 yr) Male 14-17.3 g/dL Female 11.7-15.5 g/dL
Hematocrit	42% -52% in males 36% -48% in females
Reticulocytes	0.5% -2.5% of total RBC count
White blood cells (total)	4.5-11.1 103/mm3
Neutrophils	59% Bands 3% Segs-56%
Eosinophils	2.7%
Basophils	0.5%
Lymphocytes	34%
Monocytes	4%
Platelets	150,000-450,000/mm3

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?

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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