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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
less than body requirements would be the nursing problem with the highest priority for an adolescent with anorexia nervosa. Anorexia nervosa is characterized by a severe restriction of food intake leading to a significantly low body weight, which can have serious physical and psychological consequences. Therefore, addressing the client's malnutrition and promoting adequate nutrition intake is crucial to prevent further complications.
Disturbed Body Image, Interrupted Family Processes, and Noncompliance with treatment regimen are important nursing problems to address, but they are secondary to the client's malnutrition.
Correct Answer is C
Explanation
The correct answer is choice C. Observe both lower extremities for redness and swelling.
Choice A rationale:
Palpating all peripheral pulse points for volume and strength is important for assessing circulation, but it does not directly evaluate the effectiveness of intermittent pneumatic compression (IPC) devices.IPC devices are primarily used to prevent deep vein thrombosis (DVT) and improve venous return, so monitoring for signs of DVT is more relevant.
Choice B rationale:
Monitoring the amount of drainage from the client’s incision is crucial for assessing wound healing and detecting potential infections, but it is not related to the effectiveness of IPC devices.
Choice C rationale:
Observing both lower extremities for redness and swelling is the most important assessment for evaluating the effectiveness of IPC devices. Redness and swelling can be signs of DVT, which IPC devices are designed to prevent.Therefore, this assessment directly measures whether the devices are functioning as intended.
Choice D rationale:
Evaluating the client’s ability to use an incentive spirometer is important for preventing postoperative pulmonary complications, but it does not assess the effectiveness of IPC devices.
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