An older client is taken to the clinic by the spouse, who appears extremely worried. The spouse reports to the nurse that the client started to not make any sense and asked to visit a brother who has been dead for many years. Which action(s) should the nurse take? (Select all that apply.)

Obtain the client's tympanic temperature measurement.

Review the client's current food and medication allergies.

Ask if the client is experiencing any pain with urination.

Encourage increasing the intake of high protein foods.

Determine if the client has recently experienced a fall.

Answer and Explanation

Correct Answer : A,C,E

The correct answer/s is Choice/s A, C, and E.

Choice A rationale: Obtaining the client’s tympanic temperature measurement is a crucial step. The client’s confusion and disorientation could be symptoms of an infection, such as a urinary tract infection or pneumonia. Infections in older adults can often present with atypical symptoms, including changes in mental status. Therefore, checking the client’s temperature can help identify if the client has a fever, which is a common sign of an infection.

Choice B rationale: While it’s always important to be aware of a client’s allergies, especially when administering medications, it doesn’t directly address the immediate concern of the client’s altered mental status. Therefore, it’s not the most appropriate action to take in response to the situation described.

Choice C rationale: Asking if the client is experiencing any pain with urination is relevant because urinary tract infections (UTIs) are common in older adults and can cause confusion and other changes in mental status. Pain during urination is a common symptom of a UTI.

Choice D rationale: Encouraging the intake of high protein foods is generally a good recommendation for older adults to maintain their strength and energy levels. However, it’s not directly related to the client’s current symptoms of confusion and disorientation.

Choice E rationale: Determining if the client has recently experienced a fall is important. Falls in older adults can lead to injuries, such as a head injury, which can cause confusion and other changes in mental status. Additionally, some medications used to treat pain after a fall can also contribute to confusion.

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Correct Answer is C

Explanation

A) This option is unnecessary because droplet precautions do not require a particulate filter mask. Particulate filter masks are needed for airborne precautions. Sending the UAP for fitting delays care without providing additional safety benefits for droplet precautions.

B) While a standard face mask is appropriate for droplet precautions, the part about getting fitted for a filter mask is unnecessary. It implies that a particulate filter mask is needed, which it is not for droplet precautions. This option also incorrectly suggests that vital signs can be obtained with a standard mask, but personal care requires a particulate filter mask, which is not accurate.

C) Droplet precautions require the use of a standard face mask, not a particulate filter mask (such as an N95 respirator). Particulate filter masks are required for airborne precautions, which are necessary for diseases like tuberculosis, measles, or chickenpox. For droplet precautions, a standard surgical mask is adequate to prevent the transmission of infections like influenza. Thus, the UAP can safely provide care to the client with flu-like symptoms by wearing a standard face mask.

D) This option is unnecessary because a particulate filter mask is not required for droplet precautions. Changing assignments based on this criterion is not needed and could disrupt the workflow without enhancing safety. The focus should be on ensuring staff understand and use the appropriate PPE for droplet precautions.

A. Course breath sounds B. Decreased level of consciousness C. Seizure activity D. Irritability E. Bradycardia

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}

Explanation

Course breath sounds - Respiratory Distress

Decreased level of consciousness - Cerebral Edema

Seizure activity - Cerebral Edema

Irritability - Both (Can be associated with both cerebral edema and respiratory distress)

Bradycardia - Cerebral Edema

Rationale:

Course breath sounds - Respiratory Distress

Course breath sounds could indicate the presence of secretions or fluid in the airways, which is a sign of respiratory distress. It suggests that there might be a problem with the airway or lung function.

Decreased level of consciousness - Cerebral Edema

A decreased level of consciousness can be a sign of cerebral edema, which is the swelling of the brain due to increased intracranial pressure. This can lead to changes in the child's mental status and responsiveness.

Seizure activity - Cerebral Edema

Seizure activity can be a manifestation of cerebral edema. Swelling and pressure in the brain can irritate brain tissue and lead to seizures.

Irritability - Both (Can be associated with both cerebral edema and respiratory distress) Irritability can be seen in both cerebral edema and respiratory distress. In cerebral edema, the pressure on the brain can cause discomfort and irritability. In respiratory distress, the child may be uncomfortable due to difficulty breathing.

Bradycardia - Cerebral Edema

Bradycardia (slow heart rate) can be associated with increased intracranial pressure and cerebral edema. It can be a response to the pressure on the brain.

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An older client is taken to the clinic by the spouse, who appears extremely worried. The spouse reports to the nurse that the client started to not make any sense and asked to visit a brother who has been dead for many years. Which action(s) should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An unlicensed assistive personnel (UAP) is assigned to a client with flu-like symptoms who has been placed on droplet precautions. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Correct Answer is C

Explanation

Exhibits Click to mark whether the following are signs and symptoms of cerebral edema, respiratory distress, or both.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}

Explanation

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