Nokea
A nurse is collecting data from an older adult client who has cystitis. Which of the following findings should the nurse anticipate?
- A. Confusion
- B. Hypothermia
- C. Referred pain in the right shoulder
- D. Orange colored urine
- E. Fever
- F. Dysuria
- G. Urgency
Correct Answer: A
Rationale: Confusion is common in older adults with cystitis due to altered mental status from infection.
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A nurse is assisting in the plan of care for a client who has constipation after receiving opioid medication for incisional pain. Which of the following actions should the nurse take first?
- A. Encourage the client to increase oral intake of fluids.
- B. Auscultate the client's abdomen for bowel sounds.
- C. Provide the client privacy with a set time to defecate.
- D. Administer a fiber-based laxative to the client.
- E. Increase physical activity.
- F. Check medication history.
- G. Apply heat to the abdomen.
Correct Answer: B
Rationale: Auscultating bowel sounds assesses the underlying issue (e.g., ileus) before interventions like fluids or laxatives.
A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?
- A. WBC count 9,000/mm³ (5,000 to 10,000/mm³)
- B. Temperature 37.3° C (99.1° F)
- C. Changed mental status
- D. Diminished reflexes
Correct Answer: C
Rationale: Bladder infections (UTIs) in older adults often present atypically, with mental status changes like confusion being a hallmark due to systemic inflammation or bacteremia. WBC count of 9,000/mm³ is normal, not clearly indicating infection unless trending up; leukocytosis (e.g., >10,000) is more specific. Temperature of 37.3°C is a low-grade fever, possible but not definitive for UTI without other signs. Diminished reflexes relate to neurologic or age-related issues, not infection. Altered mental status, however, is a red flag older adults may lack classic UTI symptoms (e.g., dysuria), and confusion signals potential sepsis or delirium, per geriatric assessment guidelines. This finding warrants urgent reporting for urinalysis and treatment, preventing progression, making it the strongest indicator of a bladder infection.
A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?
- A. Encourage three large meals daily.
- B. Administer an antiemetic after each meal.
- C. Season foods with spices.
- D. Provide a high-calorie diet.
Correct Answer: D
Rationale: A high-calorie diet addresses malnutrition in AIDS by meeting increased metabolic needs. Large meals may be overwhelming, antiemetics are given before meals if needed, and spices may not be tolerated.
A nurse is providing first aid for a client who has a minor burn on one hand, which of the following actions should the nurse take? (Select all that apply.)
- A. Maintain skin integrity over the blisters.
- B. Apply ice to the larger blisters.
- C. Administer ibuprofen for pain.
- D. Run cool water over the affected area.
- E. Allow the affected area to remain open to air.
Correct Answer: A,C,D
Rationale: Maintaining blister integrity prevents infection (A), ibuprofen relieves pain (C), and cool water reduces heat and pain (D). Ice can damage tissue, and open air may increase infection risk.
A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?
- A. Elevate the head of the client's bed for 1 hr. after the feeding.
- B. Administer the feeding solution at a cold temperature.
- C. Rotate the jejunostomy tube once per day.
- D. Flush the tube with 90 mL of sterile water before and after the feeding.
Correct Answer: A
Rationale: Head elevation for 1 hour reduces aspiration risk, critical for jejunostomy care. Other options are incorrect or unnecessary.