The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?
Straining on urination and nocturia
Azotemia and anorexia.
Hematuria and proteinuria.
Fever and dysuria.
The Correct Answer is D
A. These symptoms indicate a urinary tract issue but do not necessarily indicate a high risk for injury. While they are uncomfortable, they do not typically lead to physical harm.
B. Azotemia is the build-up of waste products in the blood, and anorexia is a loss of appetite. These symptoms indicate a more severe kidney problem and do not specifically point to an increased risk of injury due to a potential UTI.
C. These symptoms suggest kidney involvement but do not necessarily indicate an imminent risk of injury. While they are important to address, they do not warrant the nursing problem of "high risk for injury due to potential urinary tract infection."
D. Fever and dysuria are classic symptoms of a urinary tract infection (UTI). A UTI can progress to a more serious infection, such as pyelonephritis, which can lead to sepsis and potentially life-threatening complications. Therefore, these symptoms indicate a high risk for injury due to the potential for a UTI to worsen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the most crucial information to provide. A scleral buckling procedure is performed to repair a retinal detachment. Any signs of detachment recurrence are critical and should be reported immediately. Directly addresses the primary goal of the surgery.
B. While maintaining the head in a specific position is often recommended post-surgery, it's not the most critical information in this context. The focus should be on identifying potential complications. Not as critical as the other options.
C. Infection is a potential complication of any surgery, but it's not the primary concern immediately post-scleral buckling. Important but not the most critical information.
D. Ambulation is generally encouraged to prevent complications like pneumonia and deep vein thrombosis, but it's not a specific concern immediately post-scleral buckling. Not directly related to the procedure.
Correct Answer is D
Explanation
A. While pain assessment is important, it's not the priority in this situation. Pain can be present in various conditions, and it doesn't necessarily indicate DVT.
B. Elevating the leg can help reduce swelling but is not the initial action. The nurse needs to rule out a serious condition like DVT first.
C. Applying ice and an elastic bandage might be appropriate for some types of swelling but is not the correct initial action for a sudden, unilateral leg swelling.
D. The client presents with sudden, unilateral leg swelling, which is a red flag for deep vein thrombosis (DVT). DVT is a serious condition that can lead to pulmonary embolism. Therefore, the nurse's priority is to assess for signs of inflammation, which are warmth and erythema.
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