A primary caregiver of an older adult client calls the nurse at the outpatient clinic due to a sudden onset of changes in the client’s behavior.

The caregiver reports to the nurse that the client normally is oriented and able to answer Questions but now is confused.

What action(s) should the nurse take? Select all that apply.

Ask if the client is experiencing any pain with urination.

Encourage increased intake of high protein foods.

Review the client’s current food and medication allergies.

Determine if the client has recently experienced a fall.

Provide instruction on taking the client’s temperature.

Answer and Explanation

Correct Answer : A,D,E

Choice A rationale
Sudden onset of confusion in an older adult could be a sign of a urinary tract infection (UTI). UTIs can cause delirium and behavioral changes in older adults. Therefore, asking if the client is experiencing any pain with urination could help identify a potential UTI.
Choice B rationale
While high protein foods are generally beneficial for health, there is no direct link between increased intake of high protein foods and sudden onset of confusion. Therefore, this option is not the most appropriate action in this situation.
Choice C rationale
Reviewing the client’s current food and medication allergies is always important in healthcare settings. However, it may not directly address the sudden onset of confusion unless the client has had a recent change in diet or medication that could have triggered an allergic reaction leading to confusion.
Choice D rationale
A recent fall could potentially cause a sudden change in mental status due to a head injury or other trauma. Therefore, determining if the client has recently experienced a fall is an appropriate action.
Choice E rationale
Fever can cause confusion, especially in older adults. Therefore, providing instruction on taking the client’s temperature can help the caregiver monitor for signs of infection that could be contributing to the client’s confusion.

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Correct Answer is B

Explanation

Choice A rationale
Gastric lavage is a procedure that involves the insertion of a tube into the stomach to remove its contents and is typically used in cases of poisoning or drug overdose. However, it should not be the first action taken. The type of chemical exposure needs to be determined first to guide appropriate treatment.
Choice B rationale
Determining the type of chemical exposure is crucial as it guides the subsequent steps in management. Different chemicals can have different effects on the body and require different treatments.
Choice C rationale
While assessing for altered sensorium is important in a child exposed to chemicals, it is not the first action. The nurse needs to identify the type of chemical the child was exposed to in order to anticipate potential complications and guide treatment.
Choice D rationale

Calling the poison control emergency number is an important step in managing a case of chemical exposure. However, having information about the type of chemical the child was exposed to can make this call more effective.

A. Select the 3 statements that the nurse should include when discussing caregiver stress with the client’s daughter. B. You made a promise to your mother that you need to keep C. Moving your mother into a care facility will show her that you do not love her D. Helping your mother should be easier than raising a child E. Involve your mother in the decision-making process F. It is okay not to love or like your mother when you are caring for her G. Take time for yourself and the other relationships that you care about

Correct Answer is ["D","E","F"]

Explanation

Choice D rationale
Involving the mother in the decision-making process can help alleviate some of the stress associated with caregiving. It allows the mother to maintain some control over her care and ensures that her needs and preferences are being met.
Choice E rationale
It is normal to have mixed feelings when caring for a loved one. Acknowledging these feelings can be an important part of managing caregiver stress.
Choice F rationale
Taking time for oneself and maintaining other relationships is crucial for caregiver well-being. It can help prevent burnout and improve the quality of care provided to the mother.

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Naxlex Comprehensive Predictor Exams

A mother rushes into the emergency department carrying her toddler who has been exposed to some cleaning products. The child has a chemical smell on their hands, face, and clothes. After ensuring the airway is patent, which action should the nurse take first?

Correct Answer is B

Explanation

The nurse uses the Modified Caregiver Strain Index (MCSI) and determines that the daughter is under significant stress caused by the assumption of her mother’s care.

Correct Answer is ["D","E","F"]

Explanation

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