Difficulty: Medium
Average Score: 95%
Simulated
Passage / Scenario
Physical ExaminationDay 1 0900:
A client who has a urinary tract infection is admitted for treatment with IV antibiotics. The client is alert and oriented x3. Respirations are equal and unlabored bilaterally. S1 and S2 heart tones noted upon auscultation. Client has hearing loss and wears glasses. Abdomen is soft with suprapubic pain on palpation rated as a 4 on a scale of 0 to 10. Client reports three episodes of urinary incontinence. Bowel sounds active in all four quadrants. Able to move all extremities.
Vital Signs
Day 1 0915:
Temperature 37.3┬░ C (99.1┬░ F)
Heart rate 90/min
Respiratory rate 15/min
Blood pressure 130/76 mm Hg
Oxygen saturation 97% on room air
Day 1 1900:
Temperature 37.3┬░ C (99.1┬░ F)
Heart rate 99/min
Respiratory rate 16/min
Blood pressure 136/88 mm Hg
Oxygen saturation 98% on room air
Nurses' Notes
Day 1 1900:
The client is alert and is oriented to person, with confusion about time and place. Client is unable to focus. The client exhibits agitation upon assessment. Client states they do not remember coming to the facility, and they are late for a provider's appointment. Reorientation to environment initiates anxiety and worsens the agitation.
Upon assessment, the nurse should recognize that the client is at risk for developing ___ as evidenced by the clientÔÇÖs ___
Correct answer
A,B
Rationale
Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
1. Delirium (A) and Orientation (B) are correct actions to take as they are common indicators of cognitive impairment and risk for adverse events.
2. Dementia (C) is the potential condition the client is at risk for developing due to cognitive decline.
3. Monitoring Stroke (D) is important as it can lead to cognitive impairments and increase the risk of developing dementia.
4. Monitoring Hearing Loss (E) is also crucial as it can impact communication and exacerbate cognitive decline.
1. Delirium (A) and Orientation (B) are correct actions to take as they are common indicators of cognitive impairment and risk for adverse events.
2. Dementia (C) is the potential condition the client is at risk for developing due to cognitive decline.
3. Monitoring Stroke (D) is important as it can lead to cognitive impairments and increase the risk of developing dementia.
4. Monitoring Hearing Loss (E) is also crucial as it can impact communication and exacerbate cognitive decline.