The nurse is working in a long-term care facility. As clients are assessed, the nurse notes that one client is confused and incontinent, which is new behavior for the client. The nurse should further assess the client, suspecting:
1. the client has had a stroke.
2. the client's oxygen level is decreased.
3. the client has cystitis.
4. the client has kidney stones.
Answer: 3
1. Stroke symptoms would be very different, including the inability to speak and paralysis.
2. If a client were experiencing chronic obstructive pulmonary disease (COPD), the nurse might check the oxygen level, but the client with decreased oxygen should not be incontinent.
3. Older clients will not respond to infection as younger clients do. Often, confusion is the first sign, and the client's temperature might be normal or low. Confusion, coupled with incontinence as a new behavior, should alert the nurse to assess for cystitis.
4. The client with kidney stones will show a decreased urine output and pain.
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