An older client's spouse reports to the nurse that there has been a behavior change in the client for the past several days. The client was recently seen by the healthcare provider at the clinic and was treated for seasonal allergies and insomnia. Which action is most important for the nurse to implement?

Encourage the client to engage in social activities.

Review medications for drug and food interactions.

Appraise light sensitivity, tiredness, and dizzy spells.

Observe carefully for extrapyramidal symptoms (EPS).

Answer and Explanation

The Correct Answer is B

A. Encouraging social activities may benefit the client in the long term but does not directly address the immediate concern of the reported behavior change.

B. Reviewing medications for drug and food interactions is crucial, especially since the behavior change could be related to new medications or combinations that the client was prescribed. This assessment can help identify any adverse effects or interactions affecting the client's mental status.

C. Appraising for light sensitivity, tiredness, and dizzy spells is important but does not directly address the most pressing concern of behavioral changes which could be medication-related.

D. Observing for extrapyramidal symptoms (EPS) is important if the client is on antipsychotic medication, but the more immediate step is to ensure that medications are not contributing to the behavior change.

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Correct Answer is B

Explanation

A. Allowing the client to hold the nurse's hand might provide temporary comfort but does not address the underlying anxiety the client is experiencing.

B. Pulling up a chair and sitting beside the client's bed shows empathy and provides emotional support, helping the client feel more secure during a vulnerable time. This approach allows the nurse to complete the vital signs while still being present for the client.
C. Telling the client to release the nurse's hand may be perceived as dismissive and could increase the client's anxiety, potentially exacerbating their distress.

D. Reassuring the client that the nurse will return after taking vital signs is important but may not provide the immediate comfort that sitting beside the client would.

A. Ask the client how often episodes of sundowning are experienced. B. Request to have the client lie as still as possible for the assessment. C. Assist the client with clarifying values about end-of-life care options. D. Question the client about the frequency of falls in recent months.

Correct Answer is D

Explanation

A. Asking about sundowning may provide some insights into the client's cognitive state, but it is not directly related to the current concerns of weight loss, energy, and appetite.

B. Requesting the client to lie still is unnecessary and may hinder the assessment of their overall functional status and mobility.

C. Discussing end-of-life care options may be appropriate in certain contexts, but it is not a priority in assessing immediate functional status and nutritional concerns.

D. Questioning the client about the frequency of falls is crucial, as it may indicate underlying health issues that could be contributing to weight loss, decreased energy, and potential mobility challenges.

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Naxlex Comprehensive Predictor Exams

While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

Correct Answer is B

Explanation

The nurse is performing a functional assessment on an older client who lost five pounds (2.27 Kg) of weight since the last visit 12 weeks ago, and who reports a decrease in energy and appetite. Which action should the nurse include during the assessment?

Correct Answer is D

Explanation

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

Exhibits Which other treatment(s) might be helpful for this client? Select all that apply.

The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The nurse is teaching dietary modifications to a client with hypertension. Which product is the best selection to include as part of the client's lunch?

Exhibits The nurse discusses the need to balance energy intake and output to maintain weight. Click to indicate whether the following actions would be effective or ineffective for this client to achieve energy balance. Each row must have one option selected.