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 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.
Correct Answer is C
Explanation
A.PSA is primarily associated with prostate health and is not an effective marker for diagnosing other male cancers. While elevated PSA levels can sometimes indicate issues related to the prostate, they are not used for diagnosing other types of cancer.
B. In fact, PSA levels are usually increased in the presence of prostate cancer. While there can be some conditions that lead to a decrease in PSA levels, cancer itself typically raises PSA levels.
C.PSA is commonly used as a screening tool for prostate cancer. Elevated PSA levels may prompt further investigation, including biopsies, to determine if cancer is present. However, it’s important to note that elevated PSA can also occur due to benign conditions like prostatitis or benign prostatic hyperplasia (BPH).
D.While PSA levels can indicate the possibility of prostate cancer, they do not provide a definitive diagnosis. A diagnosis of prostate cancer typically requires further testing, such as a prostate biopsy, to confirm the presence of cancerous cells.
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