A nurse is reviewing the medical record of an older adult client who is confused to place and time. Which of the following actions should the nurse plan to take?
Place the client on a low-protein diet
Restrict the client's intake of dietary sodium.
Ask the provider to decrease the magnesium hydroxide dosage.
Request a prescription to discontinue diphenhydramine.
The Correct Answer is C
Choice A rationale:
Placing the client on a low-protein diet is not appropriate based solely on the provided information.
Choice B rationale:
Restricting dietary sodium might be considered for specific conditions but is not directly related to the client's confusion.
Choice C rationale:
A high magnesium level can contribute to confusion in older adults. Requesting a reduction in the magnesium hydroxide dosage can help address this issue.
Choice D rationale:
Discontinuing diphenhydramine might be considered if it is contributing to the client's confusion, but there is no specific information provided to support this action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Clustering nursing care activities minimizes disruptions to the client, reduces fatigue, and allows for periods of rest in between interventions.
Choice B rationale:
Hyperoxygenating the client before suctioning helps maintain adequate oxygenation and prevents hypoxia during the suctioning procedure.
Choice C rationale:
Keeping the room well lit is not necessary for a client on mechanical ventilation and can actually disturb their rest.
Choice D rationale:
Maintaining a specific PaCO2 level might be important for some clients, but this is not a general action applicable to all mechanically ventilated clients.
Correct Answer is A
Explanation
Choice A rationale:
A high-fiber diet is not recommended during acute inflammation, as it may be too abrasive for the inflamed bowel. Diverticulitis is a condition in which small pouches in the colon become inflamed and infected. A high-fiber diet can help prevent constipation and reduce pressure in the colon, which can aggravate diverticulitis.
Choice B rationale:
Soapsuds enemas are not typically used for diverticulitis. They can cause irritation and discomfort.
Choice C rationale:
Bending at the waist has no effect on diverticulitis and is not a relevant instruction.
Choice D rationale:
Fluid restriction can lead to dehydration and constipation, which can exacerbate diverticulitis. A client with diverticulitis should drink plenty of fluids to stay hydrated and soften the stool.
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