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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
An S3 heart sound can be a normal finding during pregnancy due to increased blood volume and changes in cardiac output. It is known as a physiological S3 and is considered a benign finding in the absence of other concerning symptoms or signs.
In this case, there is no immediate need for intervention or concern regarding the S3 heart sound. It is not necessary to prepare the client for an echocardiogram or limit the client's fluids based solely on the presence of an S3 heart sound in the absence of other significant symptoms or complications.
Correct Answer is ["200"]
Explanation
To calculate the mL/hour for the erythromycin infusion, we first need to determine the infusion rate in mL/minute.
The infusion is to be completed over 30 minutes, which is equal to 0.5 hours. Next, we divide the total volume (100 mL) by the total time (0.5 hours) to get the infusion rate in mL/hour:
Infusion rate = Total volume / Total time
Infusion rate = 100 mL / 0.5 hours Infusion rate = 200 mL/hour
Therefore, the nurse should program the infusion pump to deliver the erythromycin infusion at a rate of 200 mL/hour.
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