The nurse is planning care for a female client with a lower urinary tract infection (UTI). Which of the following interventions should be the priority for the nurse to include in the client's plan of care?

Teaching the client preventive measures.

Preventing progression to complications.

Educating the client about the treatment.

Providing pain management.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Teaching preventive measures is important for reducing recurrence of urinary tract infections (UTIs). These measures may include proper hydration, perineal hygiene, and urinating after intercourse. However, addressing preventive strategies is a long-term consideration and not the immediate priority for managing the active infection or preventing acute complications.

Choice B rationale

Preventing progression to complications is the priority in lower UTIs to avoid upper urinary tract involvement, such as pyelonephritis. This involves timely antibiotic administration and monitoring for signs like fever, flank pain, or worsening urinary symptoms. Pyelonephritis can lead to systemic complications like sepsis, making prevention critical to client safety.

Choice C rationale

Educating about treatment, such as the prescribed antibiotics and their potential side effects, ensures adherence and understanding. While valuable, it does not take precedence over immediate measures to halt disease progression or complications. Education supports long-term management but follows urgent clinical priorities.

Choice D rationale

Pain management is essential for comfort, addressing dysuria or pelvic pain associated with UTIs. Methods include analgesics like phenazopyridine. However, it is a supportive measure rather than a critical intervention for preventing complications, making it secondary to stopping the progression of the infection.

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Correct Answer is D

Explanation

Choice A rationale

Asking about medication use may provide helpful information but does not address the primary concern. The symptoms of visual changes and headaches can indicate serious conditions such as increased intracranial pressure or hypertensive crisis. Immediate assessment is necessary to determine severity and prevent complications. Identifying a potential trigger does not replace the need for prompt diagnostic evaluation.

Choice B rationale

Referring the client to an eye specialist might be appropriate in cases of persistent vision issues without urgent symptoms. However, when combined with headaches, these symptoms could indicate systemic or neurological issues, such as hypertension or a brain lesion. Immediate action is required, as delayed assessment might allow for worsening of an acute condition.

Choice C rationale

Obtaining a full history and physical would provide valuable data for diagnosis. However, this approach is time-intensive and may not address the urgency of the situation. Rapid assessment, such as blood pressure measurement, takes precedence to identify conditions that could be immediately life-threatening, such as hypertensive emergencies.

Choice D rationale

Measuring blood pressure promptly assesses for hypertensive crises, a common cause of vision changes and headaches. Hypertensive crises require immediate treatment to prevent end-organ damage. Normal blood pressure ranges are typically 120/80 mmHg, and values exceeding 180/120 mmHg indicate a crisis. This action provides quick, actionable information critical for patient safety.

A. Reports of fatigue. B. Hemorrhage. C. Petechiae. D. Reports of headache.

Correct Answer is B

Explanation

Choice A rationale

Fatigue can occur in thrombocytopenia due to associated bleeding or anemia, but it is not a hallmark symptom specific to low platelet counts alone. Fatigue relates more to overall systemic effects or concurrent conditions rather than isolated thrombocytopenia. Hemorrhage and petechiae, however, are more directly correlated with reduced platelets in circulation, which compromise clotting and vascular integrity.

Choice B rationale

Hemorrhage is a major concern in thrombocytopenia due to severely reduced platelet counts. Normal platelet levels range from 150,000–450,000/mm³, and values of 18,000/mm³ indicate critical impairment in clot formation, increasing the risk of spontaneous bleeding. Hemorrhagic events in vital organs pose life-threatening consequences, making monitoring and interventions essential to minimize complications associated with uncontrolled bleeding.

Choice C rationale

Petechiae are pinpoint hemorrhages visible on the skin or mucosal surfaces, indicating capillary bleeding due to insufficient platelet-mediated clotting. Normal platelet levels maintain vascular integrity by enabling clot formation, which prevents such microvascular bleeding. Platelet counts as low as 18,000/mm³ lead to abnormal hemorrhagic manifestations, making petechiae a frequent and observable sign in severe thrombocytopenia cases.

Choice D rationale

Headache can occur with thrombocytopenia if intracranial hemorrhage develops, but it is not an expected symptom in all cases. While bleeding risks elevate overall concerns, headache depends on specific organ involvement. Petechiae and systemic hemorrhage are primary symptoms associated with low platelet levels. Headaches without evidence of bleeding do not distinctly correlate with thrombocytopenia diagnosis.

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The nurse is planning care for a female client with a lower urinary tract infection (UTI). Which of the following interventions should be the priority for the nurse to include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a health screening for a client at a local clinic and the client states, "I have noticed changes in my vision recently and I have also had some bad headaches.”. Which of the following actions should be a priority for the nurse to take?

Correct Answer is D

Explanation

The nurse is caring for a client with thrombocytopenia whose platelet level is 18,000/mm³. Which of the following assessment findings should the nurse expect?

Correct Answer is B

Explanation

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