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 ["1.3"]

Explanation

1. Convert the infant's weight from pounds to kilograms. We can use the conversion factor 1 kg

= 2.2 lb. So, 22 lb x (1 kg / 2.2 lb) = 10 kg.

2. Calculate the total daily dose of amoxicillin for the infant. We can use the formula D = d x W, where D is the total daily dose, d is the dose per kg per day, and W is the weight in kg. So, D = 20 mg x 10 kg = 200 mg.
3. Calculate the single dose of amoxicillin for the infant. We can divide the total daily dose by the number of doses per day. Since the prescription is for every 8 hours, there are 3 doses per day. So, 200 mg / 3 = 66.67 mg.
4. Calculate the volume of amoxicillin suspension for the single dose. We can use the ratio of the concentration of the suspension, which is 250 mg per 5 mL. So, 66.67 mg x (5 mL / 250 mg) =
1.33 mL.
5. Round the volume to the nearest tenth= 1.3 mL

A. The amount of time the child was submerged B. Temperature of water C. Whether or not anyone witnessed the fall into the pool D. Oxygen concentration of the ambient air E. The weight of the child

Correct Answer is ["A","C","D"]

Explanation

A) Correct- The duration of submersion is a critical factor in determining the potential level of hypoxemia. Prolonged submersion leads to a higher risk of severe hypoxia and its associated complications.
B) Incorrect- While water temperature can affect the body's response to submersion, it is not directly related to the level of hypoxemia. Hypoxemia primarily results from the lack of oxygen intake during submersion.
C) Correct- Witnessing the fall into the pool is important because immediate initiation of cardiopulmonary resuscitation (CPR) can improve the chances of a positive outcome. Bystander CPR can help maintain oxygenation and circulation until professional help arrives.
D) Correct- The oxygen concentration in the surrounding air is crucial for oxygen delivery to the body's tissues. In cases of submersion, the availability of oxygen in the air the child is breathing plays a role in determining the level of hypoxemia.
E) Incorrect- The weight of the child is not a significant factor in determining the level of hypoxemia during submersion. The primary determinants are factors like submersion duration, availability of oxygen, and prompt initiation of CPR.

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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

Correct Answer is ["1.3"]

Explanation

Exhibits here Review H and P. What factors are important in determining the level of hypoxemia that the child may have experienced during the submersion? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

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