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","B","D","E"]
Explanation
Nursing Interventions for Client Starting Clonazepam:
The following nursing interventions are appropriate for the client starting clonazepam 0.25 mg PO every 12 hours:
a. Screen for orthostatic hypotension:
Rationale:
- Clonazepam,like other benzodiazepines,can cause central nervous system (CNS) depression,which can lead to hypotension,particularly orthostatic hypotension.This occurs when blood pressure drops suddenly upon standing due to impaired autonomic nervous system regulation.
- Screening for orthostatic hypotension involves measuring the client's blood pressure and heart rate while lying down and then again after standing for 3 minutes.A significant drop in blood pressure (systolic decrease of 20 mmHg or diastolic decrease of 10 mmHg) or increase in heart rate (over 20 beats per minute) indicates orthostatic hypotension.
- Monitoring for orthostatic hypotension is crucial to prevent falls and other complications,especially in older adults or those with pre-existing cardiovascular conditions.
b. Provide oral care at least twice a day:
Rationale:
- Clonazepam can cause dry mouth as a side effect,which can increase the risk of cavities,gum disease,and oral infections.
- Regular oral care helps to remove plaque and bacteria,promoting oral hygiene and preventing complications.Providing oral care at least twice a day,especially before bedtime and upon waking,is essential.
d. Assess mental status regularly:
Rationale:
- Clonazepam,while indicated for anxiety and insomnia,can paradoxically cause agitation,confusion,and even hallucinations in some individuals,particularly older adults or those with pre-existing psychiatric conditions.
- Regular assessment of mental status helps to identify any adverse behavioral or cognitive changes early on.This includes monitoring for anxiety,depression,suicidal ideation,confusion,disorientation,hallucinations,and changes in sleep patterns.
e. Assist the client to the bathroom:
Rationale:
- Clonazepam can cause drowsiness and dizziness,which can increase the risk of falls,especially in older adults or those with impaired mobility.
- Assisting the client to the bathroom and providing support during toileting activities helps to prevent falls and injuries.
Choices not included:
c. Monitor calcium levels:
- There is no specific indication for monitoring calcium levels with clonazepam use.
f. Have an opioid agonist at the bedside:
- Clonazepam is not indicated for pain management and does not interact significantly with opioid analgesics.Therefore,having an opioid agonist readily available is not a necessary intervention for clonazepam initiation.
Additional Considerations:
- Educate the client about the potential side effects of clonazepam,including drowsiness,dizziness,dry mouth,and cognitive changes.
- Advise the client to avoid alcohol and other CNS depressants while taking clonazepam,as this can increase the risk of sedation and respiratory depression.
- Instruct the client to take clonazepam exactly as prescribed and not to stop taking it abruptly,as this can lead to withdrawal symptoms.
- Monitor the client's sleep patterns and adjust the medication schedule if necessary.
Correct Answer is D
Explanation
A) Incorrect- This is true; the diaphragm should be inserted before sexual activity. However, the main concern in this scenario is the need for refitting after childbirth.
B) Incorrect- This statement is not accurate. While the diaphragm is a form of contraception, it is not considered one of the most effective methods. Long-acting reversible contraceptives
(LARCs) like intrauterine devices (IUDs) and hormonal implants are among the most effective methods.
C) Incorrect- Vaseline lubricant can be used when inserting the diaphragm: Vaseline and other oil-based lubricants can weaken the latex or cause damage to the diaphragm. Water-based lubricants are recommended for use with diaphragms.
D) Correct- The diaphragm is a barrier contraceptive device that is inserted into the vagina before sexual intercourse to prevent pregnancy. However, its effectiveness can be compromised by changes in the anatomy of the vaginal canal, cervix, and pelvic structures, such as those that occur after childbirth. After vaginal childbirth, the pelvic structures may undergo changes, including stretching and possible loss of tone. These changes can affect the fit and position of the diaphragm, leading to decreased contraceptive efficacy. Therefore, it's important for women who have given birth to have their diaphragm refitted by a healthcare provider before resuming its use.
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