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Scenario: A 75-year-old female with a history of asthma and type 2 diabetes mellitus began to experience burning upon urination, lower abdominal pain, and frequent urination a few days ago. After trying to manage her symptoms by increasing fluids, she arrived at the emergency department with her daughter with complaints of right flank pain, fever, and malaise. Her daughter said that the patient who is normally alert and oriented is now experiencing some confusion. Urinalysis results show bacteriuria, hematuria, and white blood cell casts. The nurse documents the following assessment findings:

____    Temperature 102.2◦F (39◦C)

____    Heart rate = 94 bpm

____    Blood pressure = 138/76 mmHg

____    Respirations = 20 breaths per minute

____    Right sided costovertebral angle tenderness

____    Patient reports malaise

____    Reports 1 pack per day cigarette use

____    Patient not oriented to place and time

____    Patient reports nausea

 

Cognitive Skill: Recognize Cues

Give Rationales to your answers

 

 

 

 

1. NGN Item Type: Extended Multiple Response

Place a check mark next to the assessment findings that require follow-up by the nurse.

 

Answers:

___       Temperature 102.2◦ F (39◦C)

____     Heart rate = 94 bpm

____     Blood pressure = 138/76 mm Hg

____    Respirations = 20 breaths per minute

___      Right sided costovertebral angle tenderness

___      Patient reports malaise

____    Reports 1 pack per day cigarette use

___      Patient not oriented to place and time

____    Patient reports nausea

 

Rationale for your choices: 

 

Cognitive Skill: Recognize Cues

 

 

SCIENCE
HEALTH SCIENCE
NURSING
MED SURG 116

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