1 :

Hyperlipidemia

Hypertension

0900:

52-year-old brought to the ED by their spouse. Last known well with no deficits at 0745 today. Left-sided facial droop is noted. The client is alert and oriented x4. Denies any pain. S1 and 52 are auscultated with regular rhythm and a rate of 100, and the lungs are clear to auscultation bilaterally. The abdomen is soft and nontender. Bilateral lower extremity edema 1+. Strength exam indicates significant weakness in the left upper extremity. The client reports a left visual field deficit. Skin is clean, dry, and intact. The exam is otherwise unremarkable.

0900:

Temperature 98.5° F (36.9°C)

Heart rate 100 beats/min

Respiratory rate 20 breaths/min

Blood pressure 200/102 mm Hg

Oxygen saturation 95% on room air

Pain 0/10


Indicate which four assessment findings require immediate follow-up by the nurse.


Answer Options

Hint : 🧠 Acute one-sided weakness, facial droop, vision loss, and severe BP = stroke priority.

Correct Answers:

  • Left sided-facial droop
  • Blood pressure
  • Left visual field deficit
  • Left arm weakness


Rationale :

✅ Left-sided facial droop

💎 Left-sided facial droop is an acute neurological deficit and is highly concerning for a stroke.

💎 Facial drooping occurs when blood flow to part of the brain is interrupted, affecting facial muscle control.

💎 Because the client was last known well at 0745 and arrived at 0900, this is a time-sensitive finding.

💎 The nurse should notify the stroke team/provider immediately because early treatment can reduce permanent brain injury.

💎 Facial droop is one of the major warning signs included in stroke recognition tools such as FAST.

✅ Blood pressure

🔷 The blood pressure is 200/102 mm Hg, which is severely elevated and requires immediate follow-up.

🔷 Severe hypertension increases the risk of worsening brain injury, bleeding, and complications during acute stroke treatment.

🔷 Blood pressure must be evaluated quickly because thrombolytic therapy has specific blood pressure safety requirements.

🔷 The nurse should continue frequent vital sign and neurological assessments while preparing for urgent stroke evaluation.

🔷 This finding is especially concerning because the client has a history of hypertension and hyperlipidemia, both major stroke risk factors.

✅ Left visual field deficit

🟢 A left visual field deficit is an acute neurological change that can occur with stroke affecting the visual pathways in the brain.

🟢 Visual field loss increases the client’s risk for injury because they may not see objects, people, or hazards on the affected side.

🟢 This finding helps localize the neurological problem and should be included in the urgent stroke assessment.

🟢 The nurse should institute safety precautions, keep needed items within the client’s visual field, and report the deficit promptly.

🟢 Sudden vision changes are considered a warning sign of acute cerebrovascular disease.

✅ Left arm weakness

🟣 Left arm weakness is a major acute focal neurological deficit and strongly supports suspected stroke.

🟣 Unilateral weakness suggests impaired motor function from interruption of blood flow to the brain.

🟣 This finding requires immediate follow-up because rapid intervention is essential to preserve brain tissue.

🟣 The nurse should assess strength, sensation, speech, swallowing, and level of consciousness while activating stroke protocols.

🟣 Left arm weakness combined with facial droop and visual deficit indicates a possible acute ischemic stroke.

❌ Body temperature

❌ The client’s temperature is 98.5° F (36.9° C), which is within the expected range.

❌ This does not suggest fever, infection, or temperature-related instability requiring immediate follow-up.

❌ Heart rate

❌ The heart rate is 100 beats/min, which is at the upper limit of normal to mildly elevated.

❌ In this scenario, it is less urgent than the acute neurological deficits and severe blood pressure elevation.

❌ Oxygen saturation

❌ The oxygen saturation is 95% on room air, which is within the acceptable range.

❌ This does not indicate acute hypoxia or respiratory compromise at this time.


Distractor Analysis :

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2 :

Hyperlipidemia

Hypertension

0900:

52-year-old brought to the ED by their spouse. Last known well with no deficits at 0745 today. Left-sided facial droop is noted. The client is alert and oriented x4. Denies any pain. S1 and 52 are auscultated with regular rhythm and a rate of 100, and the lungs are clear to auscultation bilaterally. The abdomen is soft and nontender. Bilateral lower extremity edema 1+. Strength exam indicates significant weakness in the left upper extremity. The client reports a left visual field deficit. Skin is clean, dry, and intact. The exam is otherwise unremarkable.

0900:

Temperature 98.5° F (36.9°C)

Heart rate 100 beats/min

Respiratory rate 20 breaths/min

Blood pressure 200/102 mm Hg

Oxygen saturation 95% on room air

Pain 0/10

0920:

Head computed tomography (CT) scan without contrast:

No mass, hemorrhage, or hydrocephalus


Select the most appropriate options from the choices below to complete the following sentence. The client is at immediate risk for developing and


Hint : 🧠 Acute stroke + severe BP = watch for brain bleeding and swelling.

Correct Answers

  • Blank 1 Correct Option: Intracerebral hemorrhage
  • Blank 2 Correct Option: Cerebral edema

Rationale :

Intracerebral hemorrhage

💎 The client has acute stroke-like findings: left-sided facial droop, left arm weakness, and left visual field deficit.

💎 The client’s blood pressure is 200/102 mm Hg, which is severely elevated and increases the risk of bleeding into brain tissue.

💎 Even though the initial CT shows no hemorrhage, the client remains at risk because severe hypertension can worsen vascular injury.

💎 If thrombolytic therapy is being considered for suspected ischemic stroke, uncontrolled blood pressure also increases the risk for intracerebral bleeding.

💎 The nurse should continue frequent neurological checks and report any worsening headache, vomiting, decreased level of consciousness, or neurological decline.

Cerebral edema

🔷 Acute stroke can lead to cerebral edema because injured brain tissue becomes inflamed and fluid shifts into the affected area.

🔷 Swelling can increase intracranial pressure, which can reduce cerebral perfusion and worsen neurological damage.

🔷 The client already has focal neurological deficits, so any worsening symptoms could indicate progression of brain injury or swelling.

🔷 The nurse should monitor for decreased level of consciousness, new confusion, worsening weakness, pupillary changes, vomiting, or severe headache.

🔷 Cerebral edema is an immediate concern after acute brain injury because it can progress quickly and become life-threatening.

❌ Deep venous thrombosis

❌ A stroke client can develop DVT later because weakness and immobility reduce venous return.

❌ This is not the most immediate risk compared with brain bleeding or swelling in the acute stroke window.

❌ Tachypnea

❌ Tachypnea means an increased respiratory rate, usually greater than 20/min in adults.

❌ The client’s respiratory rate is 20/min, and oxygen saturation is 95% on room air, so respiratory compromise is not the immediate concern.

❌ Hyperlipidemia

❌ Hyperlipidemia is a chronic risk factor for stroke because it contributes to atherosclerosis.

❌ It is already part of the client’s health history, not an immediate complication developing from the current acute event.


Distractor Analysis :

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3 :

Hyperlipidemia

Hypertension

0900:

52-year-old brought to the ED by their spouse. Last known well with no deficits at 0745 today. Left-sided facial droop is noted. The client is alert and oriented x4. Denies any pain. S1 and 52 are auscultated with regular rhythm and a rate of 100, and the lungs are clear to auscultation bilaterally. The abdomen is soft and nontender. Bilateral lower extremity edema 1+. Strength exam indicates significant weakness in the left upper extremity. The client reports a left visual field deficit. Skin is clean, dry, and intact. The exam is otherwise unremarkable.

0900:

Temperature 98.5° F (36.9°C)

Heart rate 100 beats/min

Respiratory rate 20 breaths/min

Blood pressure 200/102 mm Hg

Oxygen saturation 95% on room air

Pain 0/10

 

0930:

Temperature 98.5° F (36.9C)

Heart rate 99 beats/min

Respiratory rate 18 breaths/min

 

Blood pressure 180/99 mm Hg

Oxygen saturation 96% on room air

Pain 2/10

0920:

Head computed tomography (CT) scan without contrast:

No mass, hemorrhage, or hydrocephalus

 

0930:

NIH stroke scale: 9

0930:

Capillary glucose 119 mg/dL (70 to 120 mg/dL)

PT 11.2 seconds (11 to 15 seconds)

aPTT 30 seconds (25 to 40 seconds)

INR 1.1 (0.9 to 1.1)


The nurse reviews the client's diagnostic and assessment data. Which of the following is the priority concern the nurse should address first? Select all that apply.


Answer Options

Hint : 🧠 Stroke symptoms + high BP are the priorities.

Correct Answers:

  • The client's significant stroke deficits
  • The client's hypertension


Rationale :

✅ The client’s significant stroke deficits

💎 The client has acute neurological changes, including left-sided facial droop, left arm weakness, and left visual field deficit, which are consistent with a possible acute ischemic stroke.

💎 The NIH Stroke Scale score of 9 indicates measurable stroke deficits and supports the need for urgent stroke intervention.

💎 The last known well time was 0745, and the client arrived within a time-sensitive treatment window, making rapid assessment and treatment critical.

💎 The CT scan shows no hemorrhage, which is important because it supports further evaluation for ischemic stroke treatment.

💎 These stroke deficits are a priority because untreated cerebral ischemia can lead to permanent brain injury and worsening neurological function.

✅ The client’s hypertension

🔷 The client’s blood pressure remains elevated at 180/99 mm Hg, after initially being 200/102 mm Hg.

🔷 Hypertension is a priority because severe blood pressure elevation can worsen cerebral injury and increase the risk for intracerebral hemorrhage.

🔷 If thrombolytic therapy is being considered, blood pressure must be controlled within safe parameters before administration.

🔷 Ongoing hypertension also increases stress on damaged cerebral vessels and can worsen outcomes after stroke.

🔷 The nurse should continue frequent blood pressure monitoring and anticipate provider-directed blood pressure management.

❌ The client’s tachycardia

❌ The heart rate is 99 beats/min, which is not clinically significant tachycardia.

❌ The earlier heart rate of 100 beats/min is only borderline and not the priority compared with acute neurological deficits.

❌ The client’s hypoglycemia

❌ The capillary glucose is 119 mg/dL, which is within the expected range of 70 to 120 mg/dL.

❌ Hypoglycemia can mimic stroke symptoms, but this client’s glucose level does not support hypoglycemia as the cause.

❌ The client’s clotting disorder

❌ The clotting studies are within expected ranges: PT 11.2 sec, aPTT 30 sec, INR 1.1.

❌ These values do not indicate a clotting disorder and do not explain the client’s acute neurological deficits.


Distractor Analysis :

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4 :

Hyperlipidemia

Hypertension

0900:

52-year-old brought to the ED by their spouse. Last known well with no deficits at 0745 today. Left-sided facial droop is noted. The client is alert and oriented x4. Denies any pain. S1 and 52 are auscultated with regular rhythm and a rate of 100, and the lungs are clear to auscultation bilaterally. The abdomen is soft and nontender. Bilateral lower extremity edema 1+. Strength exam indicates significant weakness in the left upper extremity. The client reports a left visual field deficit. Skin is clean, dry, and intact. The exam is otherwise unremarkable.

0900:

Temperature 98.5° F (36.9°C)

Heart rate 100 beats/min

Respiratory rate 20 breaths/min

Blood pressure 200/102 mm Hg

Oxygen saturation 95% on room air

Pain 0/10

 

0930:

Temperature 98.5° F (36.9C)

Heart rate 99 beats/min

Respiratory rate 18 breaths/min

 

Blood pressure 180/99 mm Hg

Oxygen saturation 96% on room air

Pain 2/10

0920:

Head computed tomography (CT) scan without contrast:

No mass, hemorrhage, or hydrocephalus

0930:

NIH stroke scale: 9

0930:

Capillary glucose 119 mg/dL (70 to 120 mg/dL)

PT 11.2 seconds (11 to 15 seconds)

aPTT 30 seconds (25 to 40 seconds)

INR 1.1 (0.9 to 1.1)


For each potential provider order, click to specify if the intervention is indicated, nonessential, or contraindicated for this client.


Potential orders/Interventions indicated non essential containdicated
Administer alteplase (tPa)
Consult social work regarding home care assistance at discharge
Administer 5% dextrose in water [D5W) intravenously
Administer ibuprofen (Motrin)
Magnetic resonance imaging (MRI) of the brain without contrast

Hint : 🧠 Acute ischemic stroke = tPA if eligible, avoid dextrose/NSAIDs, consider MRI.

Correct Answers

  • Administer alteplase (tPa) [ indicated ]
  • Consult social work regarding home care assistance at discharge [ non essential ]
  • Administer 5% dextrose in water [D5W) intravenously [ containdicated ]
  • Administer ibuprofen (Motrin) [ containdicated ]
  • Magnetic resonance imaging (MRI) of the brain without contrast [ indicated ]

Rationale :

Administer alteplase (tPA) — Indicated

💎 The client has findings consistent with an acute ischemic stroke, including left-sided facial droop, left arm weakness, and left visual field deficit.

💎 The client was last known well at 0745 and is being evaluated at 0930, which is within the usual 4.5-hour thrombolytic treatment window.

💎 The CT scan shows no hemorrhage, which is essential before giving alteplase because tPA is contraindicated in hemorrhagic stroke.

💎 Coagulation labs are acceptable: PT 11.2 seconds, aPTT 30 seconds, INR 1.1, meaning there is no obvious clotting abnormality.

💎 Blood pressure is 180/99 mm Hg, which is below the usual tPA exclusion threshold of 185/110 mm Hg, so alteplase is appropriate if no other contraindications exist.

Consult social work regarding home care assistance at discharge — Nonessential

🔷 Social work may be helpful later because stroke clients often need rehabilitation planning, home safety evaluation, equipment support, and discharge resources.

🔷 However, this client is in the acute stroke phase, where the immediate priorities are brain perfusion, stroke treatment, neurological monitoring, and preventing complications.

🔷 Discharge planning is important, but it does not address the client’s urgent neurological deficits.

🔷 The client is still being evaluated for acute treatment, so home care planning is not the priority at this moment.

🔷 This order is appropriate later but nonessential right now.

Administer D5W intravenously — Contraindicated

🟢 D5W is hypotonic after dextrose is metabolized and can shift water into cells, which may worsen cerebral edema in a client with acute stroke.

🟢 Clients with acute brain injury are at risk for increased intracranial pressure, and hypotonic fluids can increase swelling in brain tissue.

🟢 The client’s glucose is 119 mg/dL, which is normal, so there is no hypoglycemia requiring dextrose administration.

🟢 Hyperglycemia can worsen neurological outcomes after stroke, so unnecessary dextrose-containing fluids should be avoided.

🟢 Isotonic fluids, such as 0.9% sodium chloride, are generally preferred when IV fluid support is needed in acute stroke.

Administer ibuprofen (Motrin) — Contraindicated

🟣 Ibuprofen is an NSAID that can increase the risk of bleeding, especially when thrombolytic therapy such as alteplase is being considered or administered.

🟣 In acute stroke care, medications that increase bleeding risk should be avoided unless specifically ordered after careful evaluation.

🟣 The client may receive alteplase, which already increases bleeding risk by breaking down clots.

🟣 Giving ibuprofen could increase the risk of intracranial hemorrhage or gastrointestinal bleeding.

🟣 The client only reports mild pain of 2/10, so ibuprofen is not appropriate as a priority intervention.

MRI of the brain without contrast — Indicated

🔶 MRI without contrast can provide more detailed information about ischemic brain injury than CT in some cases.

🔶 The initial CT ruled out mass, hemorrhage, and hydrocephalus, but early ischemic stroke changes may not always be visible immediately on CT.

🔶 MRI can help confirm the location and extent of infarction and guide ongoing stroke management.

🔶 A noncontrast MRI is appropriate because contrast is not always needed to evaluate acute ischemic changes.

🔶 This intervention supports diagnosis and treatment planning, especially when neurological deficits are present.


Distractor Analysis :

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5 :

Hyperlipidemia

Hypertension

0900:

52-year-old brought to the ED by their spouse. Last known well with no deficits at 0745 today. Left-sided facial droop is noted. The client is alert and oriented x4. Denies any pain. S1 and 52 are auscultated with regular rhythm and a rate of 100, and the lungs are clear to auscultation bilaterally. The abdomen is soft and nontender. Bilateral lower extremity edema 1+. Strength exam indicates significant weakness in the left upper extremity. The client reports a left visual field deficit. Skin is clean, dry, and intact. The exam is otherwise unremarkable

0900:

Temperature 98.5° F (36.9°C)

Heart rate 100 beats/min

Respiratory rate 20 breaths/min

Blood pressure 200/102 mm Hg

Oxygen saturation 95% on room air

Pain 0/10

 

0930:

Temperature 98.5° F (36.9C)

Heart rate 99 beats/min

Respiratory rate 18 breaths/min

 

Blood pressure 180/99 mm Hg

Oxygen saturation 96% on room air

Pain 2/10

0920:

Head computed tomography (CT) scan without contrast:

No mass, hemorrhage, or hydrocephalus

0930:

NIH stroke scale: 9

0930:

Capillary glucose 119 mg/dL (70 to 120 mg/dL)

PT 11.2 seconds (11 to 15 seconds)

aPTT 30 seconds (25 to 40 seconds)

INR 1.1 (0.9 to 1.1)

0900:

Head CT scan without contrast

0925:

MRI brain

0945:

Administer alteplase (tPA) per protocol

Admit client to Neurological Intensive Care Unit


The nurse prepares to administer alteplase (tPA) per the provider's order. What priority data must the nurse obtain before administration


Answer Options

Hint : ⚖️ tPA dose = weight-based medication.

Correct Answers:

  • The client's current weight


Rationale :

💎 Alteplase (tPA) dosing is based on the client's actual body weight, making an accurate current weight essential before administration.

💎 The standard dose for acute ischemic stroke is 0.9 mg/kg, with a maximum dose of 90 mg.

💎 An inaccurate weight can result in underdosing, which may reduce treatment effectiveness, or overdosing, which can increase the risk of bleeding complications, including intracranial hemorrhage.

💎 Because tPA is a high-alert medication, precise dosing calculations are critical to client safety.

💎 The nurse should obtain and verify the client's current weight before preparing and administering the medication.

❌ The client's current pain rating

❌ Pain assessment is important for overall care but does not determine the dose or eligibility for alteplase.

❌ The client reports only mild pain, and pain level is not a priority factor in tPA administration.

❌ The client's history of nicotine use

❌ Smoking history is a stroke risk factor but does not affect immediate alteplase dosing.

❌ The decision to administer tPA is based on stroke timing, imaging, neurological findings, and contraindications.

❌ The client's serum creatinine level

❌ Serum creatinine assesses kidney function and is not required for alteplase dose calculation.

❌ Alteplase dosing is weight-based rather than kidney function-based.


Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

6 :

Hyperlipidemia

Hypertension

0900:

52-year-old brought to the ED by their spouse. Last known well with no deficits at 0745 today. Left-sided facial droop is noted. The client is alert and oriented x4. Denies any pain. S1 and 52 are auscultated with regular rhythm and a rate of 100, and the lungs are clear to auscultation bilaterally. The abdomen is soft and nontender. Bilateral lower extremity edema 1+. Strength exam indicates significant weakness in the left upper extremity. The client reports a left visual field deficit. Skin is clean, dry, and intact. The exam is otherwise unremarkable.

 

1030:

Client with new onset of aphasia but improved facial droop. The client reports a severe headache.

0900:

Temperature 98.5° F (36.9°C)

Heart rate 100 beats/min

Respiratory rate 20 breaths/min

Blood pressure 200/102 mm Hg

Oxygen saturation 95% on room air

Pain 0/10

 

0930:

Temperature 98.5° F (36.9C)

Heart rate 99 beats/min

Respiratory rate 18 breaths/min

 

Blood pressure 180/99 mm Hg

Oxygen saturation 96% on room air

Pain 2/10

 

0945

Heart rate 95 beats/min

Respiratory rate 18 breaths/min

Blood pressure 178/96 mm Hg

Oxygen saturation 98% on room air

1030:

Heart rate 90 beats/min

Respiratory rate 18 breaths/min

Blood pressure 165/95 mm Hg

Oxygen saturation 99% on room air

Pain 9/10, headache

0920:

Head computed tomography (CT) scan without contrast:

No mass, hemorrhage, or hydrocephalus

0930:

NIH stroke scale: 9

0930:

Capillary glucose 119 mg/dL (70 to 120 mg/dL)

PT 11.2 seconds (11 to 15 seconds)

aPTT 30 seconds (25 to 40 seconds)

INR 1.1 (0.9 to 1.1)

0900:

Head CT scan without contrast

0925:

MRI brain

0945:

Administer alteplase (tPA) per protocol

Admit client to Neurological Intensive Care Unit


Click to highlight the findings below that indicate that the client is NOT progressing as expected.


New onset of aphasia Severe headache Pain 9/10, headache

Hint : 🧠 After tPA, new neuro deficits + sudden severe headache = think intracranial hemorrhage.

Correct Highlights :
  • New onset of aphasia
  • Severe headache
  • Pain 9/10, headache

Rationale :

✅ New onset of aphasia

💎 The development of new aphasia after receiving alteplase is an unexpected neurological change and requires immediate follow-up.

💎 Aphasia indicates worsening neurological function and may suggest expansion of the stroke, decreased cerebral perfusion, or intracranial bleeding.

💎 Following tPA administration, any new neurological deficit should be treated as a potential emergency.

💎 The nurse should immediately stop any unnecessary activity, perform a neurological assessment, and notify the provider or stroke team.

💎 New neurological symptoms after thrombolytic therapy are concerning for complications such as intracerebral hemorrhage.

✅ Severe headache

🔷 A sudden severe headache following alteplase administration is a classic warning sign of possible intracranial hemorrhage.

🔷 Headache occurring with new neurological changes is especially concerning in a client receiving thrombolytic therapy.

🔷 Intracranial bleeding is one of the most serious complications of tPA treatment.

🔷 The nurse should anticipate urgent neurological reassessment and repeat brain imaging.

🔷 Severe headache should never be dismissed in a stroke client after thrombolytic therapy.

✅ Pain 9/10, headache

🟢 The client's pain increased from 0/10 initially to 9/10 at 1030, which represents a significant deterioration.

🟢 This severe pain is associated with the reported headache and supports concern for intracranial bleeding or worsening cerebral injury.

🟢 Sudden severe headache with high pain intensity is not an expected recovery finding after tPA administration.

🟢 The nurse should immediately report this change and continue close neurological monitoring.

🟢 Severe headache following thrombolytic therapy is considered a high-priority finding.

❌ Heart rate 90 beats/min

❌ A heart rate of 90 beats/min is within the expected adult range.

❌ The heart rate has improved from earlier values and does not indicate deterioration.

❌ Respiratory rate 18 breaths/min

❌ A respiratory rate of 18 breaths/min is within the normal range.

❌ There is no evidence of respiratory compromise or worsening respiratory status.

❌ Blood pressure 165/95 mm Hg

❌ Although elevated, the blood pressure has decreased from 200/102 mm Hg and 180/99 mm Hg.

❌ This trend suggests improvement rather than deterioration in blood pressure control.

❌ Oxygen saturation 99% on room air

❌ An oxygen saturation of 99% indicates excellent oxygenation.

❌ This finding does not suggest worsening neurological or respiratory status.

❌ NIH Stroke Scale 7

❌ The NIH Stroke Scale improved from 9 to 7.

❌ A lower NIHSS score indicates improved neurological function and reduced stroke severity.


Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

7 :

Hypertension, well-controlled on lisinopril (Zestril) 20 mg PO daily

Allergy to penicillin

Records indicate four episodes of acute UTI in the last year. The last episode was one month ago.

0900:

The client presents to ED with urinary frequency, urgency, and bouts of nausea. In addition, the family reports that the client has been confused on and off over the last two days with a poor appetite.

The client is alert and oriented to person and place on exam but disoriented regarding the date and time. Reports abdominal/pelvic pain 6/10. Urine is cloudy with a foul smell and gross hematuria.

Time:0900
Temperature °F (℃)101.8°F (38.7C)
Heart rate (bpm)108
Respiratory rate (bpm)24
Blood pressure (mm Hg)118.72
Oxygen saturation96% on room air
Pain6/10 pelvic

The nurse has just completed their initial assessment. Please select the three findings that require immediate follow-up from the options listed.


Answer Options

Hint : 🦠 Older adult UTI + fever + confusion + tachypnea = possible systemic infection.

Correct Answers:

  • Temperature
  • Mental status
  • Respiratory rate


Rationale :

✅ Temperature

💎 The client’s temperature is 101.8°F (38.7°C), which indicates a fever and suggests an active infection.

💎 In an older adult with UTI symptoms, fever raises concern that the infection may be worsening or spreading beyond the lower urinary tract.

💎 Fever combined with tachycardia, tachypnea, confusion, cloudy foul-smelling urine, and hematuria increases concern for systemic infection or early sepsis.

💎 This requires prompt follow-up because older adults can deteriorate quickly when infection becomes systemic.

💎 The nurse should anticipate urine culture, blood work, hydration support, and antibiotic therapy based on provider orders.

✅ Mental status

🔷 New or intermittent confusion in an older adult with a UTI is a priority finding.

🔷 The client is disoriented to date and time, and the family reports confusion over the last two days.

🔷 Acute mental status change can indicate delirium, which is often triggered by infection, dehydration, hypoxia, electrolyte imbalance, or sepsis in older adults.

🔷 This finding requires immediate follow-up because worsening confusion can increase fall risk, impair safety, and signal clinical decline.

🔷 The nurse should continue neurological checks, assess hydration and infection severity, and report worsening orientation changes promptly.

✅ Respiratory rate

🟢 The respiratory rate is 24/min, which is elevated and indicates tachypnea.

🟢 Tachypnea can be an early sign of systemic infection or sepsis because the body increases respiratory effort in response to fever, inflammation, or metabolic stress.

🟢 In this case, tachypnea occurs with fever, tachycardia, and altered mental status, making it more concerning.

🟢 A respiratory rate above 20/min is clinically significant in infection screening and should not be ignored.

🟢 The nurse should reassess breathing pattern, monitor oxygenation, and report this finding with the rest of the infection-related changes.

❌ Poor appetite

❌ Poor appetite is common in older adults with infection and can contribute to dehydration or weakness.

❌ It is important to monitor, but it is not as immediately concerning as fever, confusion, or tachypnea.

❌ The nurse should encourage fluids and nutrition as tolerated once urgent infection-related concerns are addressed.

❌ Poor intake may support the overall concern for illness but is not the highest-priority follow-up finding.

❌ It does not indicate immediate instability by itself.

❌ Blood pressure

❌ The blood pressure is 118/72 mm Hg, which is within an acceptable range.

❌ This does not show hypotension or shock at this time.

❌ In sepsis, falling blood pressure would be a late and serious sign, but that is not present here.

❌ The nurse should continue monitoring because infection can progress.

❌ This value does not require immediate follow-up compared with the abnormal findings.

❌ Oxygen saturation

❌ The oxygen saturation is 96% on room air, which is within the expected range.

❌ This indicates adequate oxygenation at the time of assessment.

❌ Although the respiratory rate is elevated, oxygen saturation is not currently low.

❌ The nurse should continue monitoring for changes.

❌ This finding does not require immediate follow-up right now.


Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

8 :

Hypertension, well-controlled on lisinopril (Zestril) 20 mg PO daily

Allergy to penicillin

Records indicate four episodes of acute UTI in the last year. The last episode was one month ago.

0900:

The client presents to ED with urinary frequency, urgency, and bouts of nausea. In addition, the family reports that the client has been confused on and off over the last two days with a poor appetite.

The client is alert and oriented to person and place on exam but disoriented regarding the date and time. Reports abdominal/pelvic pain 6/10. Urine is cloudy with a foul smell and gross hematuria.

Time:0900
Temperature °F (℃)101.8°F (38.7C)
Heart rate (bpm)108
Respiratory rate (bpm)24
Blood pressure (mm Hg)118.72
Oxygen saturation96% on room air
Pain6/10 pelvic

 

 


Click to indicate whether each symptom in the table correlates with an acute urinary tract infection (UTI): cystitis, pyelonephritis, or urosepsis.


Sign or Symptom Cystitis pyelonephritis urosepsis
Tachypnea/tachycardia
Low back/flank pain
Dysuria/ urgency/frequency
Hematuria
Fever
Hypotension
Costovertebral angle (CVA) tenderness

Hint : 🚻 Bladder = dysuria/frequency/hematuria; Kidney = fever/flank pain/CVA tenderness; Sepsis = tachycardia/tachypnea/hypotension.

Correct Answers

  • Tachypnea/tachycardia [ urosepsis ]
  • Low back/flank pain [ pyelonephritis ]
  • Dysuria/ urgency/frequency [ Cystitis ]
  • Hematuria [ Cystitis ]
  • Fever [ pyelonephritis ]
  • Hypotension [ urosepsis ]
  • Costovertebral angle (CVA) tenderness [ pyelonephritis ]

Rationale :

✅ Tachypnea/Tachycardia → Urosepsis

💎 Tachycardia and tachypnea are common manifestations of a systemic inflammatory response caused by infection.

💎 These findings suggest the urinary infection has spread beyond the urinary tract and may be progressing to sepsis.

✅ Low Back/Flank Pain → Pyelonephritis

🔷 Flank pain occurs when infection involves the kidneys rather than remaining in the bladder.

🔷 Pain is typically felt in the lower back near the costovertebral angles.

✅ Dysuria/Urgency/Frequency → Cystitis

🟢 Dysuria, urinary urgency, and frequency are classic symptoms of a lower urinary tract infection (bladder infection).

🟢 These symptoms occur due to irritation and inflammation of the bladder mucosa.

✅ Hematuria → Cystitis

🟣 Inflammation of the bladder lining can cause blood in the urine.

🟣 Gross or microscopic hematuria is commonly seen with acute cystitis.

✅ Fever → Pyelonephritis

🔶 Fever is more commonly associated with an upper urinary tract infection involving the kidneys.

🔶 Kidney infections produce a more significant systemic inflammatory response than cystitis.

✅ Hypotension → Urosepsis

⭐ Hypotension is a serious sign that infection may be progressing to sepsis or septic shock.

⭐ It occurs due to widespread vasodilation and impaired tissue perfusion.

✅ Costovertebral Angle (CVA) Tenderness → Pyelonephritis

💠 CVA tenderness is a hallmark finding of kidney infection.

💠 Pain occurs when the inflamed kidney is palpated or percussed over the flank area.


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9 :

Hypertension, well-controlled on lisinopril (Zestril) 20 mg PO daily

Allergy to penicillin

Records indicate four episodes of acute UTI in the last year. The last episode was one month ago.

0900:

The client presents to ED with urinary frequency, urgency, and bouts of nausea. In addition, the family reports that the client has been confused on and off over the last two days with a poor appetite.

The client is alert and oriented to person and place on exam but disoriented regarding the date and time. Reports abdominal/pelvic pain 6/10. Urine is cloudy with a foul smell and gross hematuria.

 

1100:

The client is alert and oriented to person, remains confused, and now requires frequent reorientation to place and situation. Acetaminophen (Tylenol) was administered at 1030. The client has had 150 ml oral intake since 0900 this morning and continues to report nausea. The client continues to report urinary frequency, but the phenazopyridine (Pyridium) has helped with the pain and dysuria. The client is tachycardic, febrile, and now also hypotensive.

Time:09001100 
Temperature °F (℃)101.8°F (38.7C)102.2°F (39℃) 
Heart rate (bpm)108110 
Respiratory rate (bpm)2426 
Blood pressure (mm Hg)118.7288/48 
Oxygen saturation96% on room air95% on room air 
Pain6/10 pelvic3/10 pelvic 

930:

TestResultReference Range  
WBC16,000/mm34,500-11,000/mm3  
Potassium4.0 mEq/L3.5-5.0 mEq/L  
Sodium140 mEq/L136-145 mEq/L  
BUN22 mg/dL7-18 mg/dL  
Creatinine1.5 mg/dL0.6-1.2 mg/dL  
Lactic acid 2.5 mmol/L 0.5-2 mmol/L

Select the most appropriate options from the choices below to complete the statement regarding how the nurse should prioritize the plan of care given the client's changing condition. The nurse should first address the client's [blank1] and [blank2]


Answer Options

Hint : 🦠 Urosepsis priority = low BP + high lactate.

Correct Answers:

  • Blood pressure
  • Serum BUN/Cr


Rationale :

✅ Blood pressure

💎 The client’s blood pressure has dropped from 118/72 mm Hg to 88/48 mm Hg, which indicates hypotension.

💎 Hypotension in a client with UTI, fever, tachycardia, tachypnea, confusion, and elevated WBC is highly concerning for urosepsis.

💎 Low blood pressure means the client may not be perfusing vital organs adequately, increasing the risk for shock, kidney injury, altered mental status, and organ failure.

💎 This is the first priority because circulation and tissue perfusion must be supported immediately.

💎 The nurse should anticipate rapid IV fluids, blood/urine cultures, broad-spectrum antibiotics, close vital-sign monitoring, and possible vasopressor support if hypotension persists.

✅ Serum lactic acid

🔷 The client’s lactic acid is 2.5 mmol/L, which is elevated above the normal range of 0.5 to 2 mmol/L.

🔷 Elevated lactate suggests impaired tissue perfusion and anaerobic metabolism, often seen in sepsis.

🔷 In this client, the elevated lactate combined with hypotension, fever, tachycardia, tachypnea, confusion, and leukocytosis strongly supports worsening systemic infection.

🔷 Lactic acid is important because it helps determine the severity of sepsis and guides urgent treatment decisions.

🔷 The nurse should report this finding promptly and anticipate sepsis protocol interventions.

❌ Temperature

❌ The temperature is 102.2°F (39°C), which confirms ongoing infection and requires treatment.

❌ However, fever is not the first priority compared with hypotension and elevated lactate, which indicate poor perfusion and possible sepsis progression.

❌ Serum potassium

❌ The potassium level is 4.0 mEq/L, which is within the expected range of 3.5 to 5.0 mEq/L.

❌ This value does not indicate an immediate electrolyte imbalance requiring priority intervention.

❌ Serum BUN/Cr

❌ The BUN is 22 mg/dL and creatinine is 1.5 mg/dL, both mildly elevated and concerning for possible dehydration or decreased kidney perfusion.

❌ These values require monitoring, but the immediate priority is correcting the hypotension and poor tissue perfusion causing kidney stress.

❌ Nausea

❌ Nausea is uncomfortable and contributes to poor oral intake, but it is not the most urgent threat.

❌ The client’s signs of urosepsis and hypotension must be addressed before symptom comfort measures.


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10 :

Hint : 🧠 SCI above T6 → think autonomic dysreflexia = severe hypertension + headache.

Correct Answers:

  • Autonomic dysreflexia: A life-threatening complication that occurs in clients with a spinal cord injury above T 6


Rationale :

💎 Autonomic dysreflexia is a potentially life-threatening emergency that occurs most commonly in clients with spinal cord injuries at or above T6.

💎 It results from an exaggerated sympathetic nervous system response to stimuli below the level of injury, such as a distended bladder, fecal impaction, pressure injury, or tight clothing.

💎 Manifestations include severe hypertension, bradycardia, pounding headache, flushing above the injury level, diaphoresis, and nasal congestion.

💎 If untreated, autonomic dysreflexia can lead to stroke, seizures, retinal hemorrhage, cardiac complications, and death.

💎 Immediate nursing interventions include sitting the client upright, removing the triggering stimulus, and monitoring blood pressure closely.

❌ Poikilothermia: A type of neurogenic shock that occurs in clients with a spinal cord injury above T6

❌ Poikilothermia is the inability to regulate body temperature, causing the body temperature to vary with the environment.

❌ It is not a form of neurogenic shock and is unrelated to the acute hemodynamic changes seen in neurogenic shock.

❌ Autonomic dysreflexia: Poikilothermia is the body's loss of ability to control and regulate body temperature

❌ This option incorrectly combines two different conditions into one statement.

❌ Poikilothermia and autonomic dysreflexia are separate complications with different causes and manifestations.

❌ Neutropenia: An abnormally low neutrophil count

❌ This statement is factually correct regarding the definition of neutropenia.

❌ However, neutropenia is a hematologic disorder and is not a specific complication associated with spinal cord injury, making option B the best answer.


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