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","C","D","E"]

Explanation

A. Multiple myeloma can lead to dehydration and kidney problems. Increasing fluid intake helps to prevent these complications and can also help to reduce the risk of infections.
B. This statement is incorrect. Aspirin should not be taken unless prescribed by a doctor. It can increase the risk of bleeding in people with multiple myeloma.
C. Multiple myeloma can weaken the immune system, making the client more susceptible to infections. Using fragrance-free gel soap can help to reduce the risk of skin irritation and infections.
D. Multiple myeloma can cause bone pain. Using analgesics as needed can help to manage this pain and improve the client's quality of life.
E. Multiple myeloma can weaken bones, increasing the risk of fractures. Installing grab bars in the shower can help to prevent falls and reduce the risk of injuries.

A. Petechiae and epistaxis B. Generalized edema and rash C. Alopecia and pallor D. Bradycardia and lethargy

Correct Answer is A

Explanation

A. Petechiae (small red or purple spots caused by bleeding under the skin) and epistaxis (nosebleeds) result from thrombocytopenia, which is a low platelet count often seen in leukemia. The compromised bone marrow function leads to inadequate production of platelets, resulting in bleeding and bruising.
B. While generalized edema and rash can occur in various conditions, they are not specific to ALL and are not common initial findings. Edema might be seen in certain contexts (e.g., renal involvement or fluid overload), but it is not a hallmark of ALL.
C. Alopecia (hair loss) and pallor (paleness) can occur in clients undergoing chemotherapy for ALL, but they are not typically initial findings at the time of diagnosis. Pallor may result from anemia, which can develop as a consequence of the disease, but it is not the most immediate or characteristic symptom of ALL.
D. Bradycardia (slow heart rate) and lethargy are not typical initial findings of ALL. Lethargy could be present due to anemia or other systemic effects, but bradycardia is not commonly associated with the disease and would require further investigation for other underlying causes.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","D","E"]

Explanation

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Correct Answer is A

Explanation

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