Which of the following is an early sign that an infection is developing in an older adult client?
Wheezes in the bronchioles.
Urinary retention.
Low back pain.
Confusion.
The Correct Answer is D
Choice A rationale
Wheezing is typically indicative of airway narrowing, bronchospasm, or fluid overload in the pulmonary vasculature, such as in asthma or heart failure. While a respiratory infection might eventually cause adventitious breath sounds, wheezing is not considered a primary or early systemic sign of infection in the elderly. It is more specific to the mechanics of the lower respiratory tract rather than a generalized infectious response or early neuro-immunological shift.
Choice B rationale
Urinary retention is the inability to empty the bladder and is often related to prostatic hypertrophy in men, neurological issues, or medication side effects like anticholinergics. While a urinary tract infection can sometimes cause frequency or urgency, retention is not a standard early diagnostic sign of systemic infection. In the geriatric population, the focus for early infection detection is usually on mental status changes rather than localized obstructive urinary symptoms.
Choice C rationale
Low back pain is a common musculoskeletal complaint in older adults due to degenerative disc disease, spinal stenosis, or osteoarthritis. While localized pain can occur with pyelonephritis, it is not a sensitive or early indicator for the broad spectrum of infections. Many older adults have baseline chronic pain, making it a poor marker for a new infectious process. It lacks the systemic significance required for early identification of sepsis or infection.
Choice D rationale
Confusion or acute change in mental status, often termed delirium, is a classic and frequently the only early sign of infection in older adults. Unlike younger patients who may present with high fevers (normal range 36.5 to 37.5 degrees Celsius), the elderly often have a blunted immune response and may remain afebrile. Changes in cerebral perfusion and the effects of inflammatory cytokines on the aging brain manifest as cognitive impairment or disorientation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.2"]
Explanation
Step 1 is 2 mg ÷ 10 mg/mL.
Step 2 is 0.2 mL. .
Correct Answer is D
Explanation
Choice A rationale
Lecture is a passive teaching method where the educator provides information to the learner without requiring immediate participation or verification of understanding. It is useful for delivering large amounts of information to groups but does not allow the nurse to assess the client's actual retention or physical ability to perform a task. In this scenario, the nurse is actively seeking a demonstration of understanding from the client, which exceeds the scope of a lecture.
Choice B rationale
Role play involves the nurse and client acting out a scenario to practice social or communication skills. While it can be used for teaching, it is usually focused on emotional responses or complex interpersonal interactions rather than the verification of a specific technical procedure like eye drop instillation. The nurse in this question is asking for a verbalization of steps rather than acting out a situational scenario between two distinct characters or roles.
Choice C rationale
Query and answer, or question and answer, is a method used to clarify specific points or address gaps in knowledge. While the nurse is asking the client a question, the specific intent of asking the client to explain the entire procedure back is a structured pedagogical technique. Query and answer sessions are typically more fragmented and focused on individual facts rather than a comprehensive assessment of the client's ability to synthesize and repeat instructions.
Choice D rationale
Teach-back is a formal evidence-based communication loop where the nurse asks the client to explain the information or procedure in their own words. This method confirms that the client understands the teaching and allows the nurse to correct any misconceptions immediately. It is the gold standard for verifying health literacy and ensuring safety in self-administration of medications. By having the client explain the steps, the nurse ensures the instructions were clear and understood.
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