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?

Review medications for drug and food interactions.

Observe carefully for extrapyramidal symptoms (EPS)

Appraise light sensitivity, tiredness, and dizzy spells.

Encourage the client to engage in social activities.

Answer and Explanation

The Correct Answer is A

Rationale

A. Older adults are more susceptible to medication side effects due to changes in metabolism and polypharmacy. Reviewing the client's current medications, including over-the-counter medications for allergies and insomnia, can identify potential culprits.

B. Some medications used for allergies or insomnia, such as antihistamines or sedatives, can cause EPS in older adults. EPS include symptoms like tremors, rigidity, or involuntary movements. These symptoms can indicate adverse reactions that require immediate attention and adjustment of medication.

C. These symptoms could be side effects of medications commonly used for allergies and insomnia. They may also indicate other underlying health issues or medication interactions. Assessing these symptoms helps in determining their severity and whether they require further evaluation or intervention.

D. Social isolation can contribute to changes in behavior, especially in older adults. While social activities are beneficial for mental health, in this case, addressing the potential medication-related issues (options A and B) takes precedence to ensure the client's safety and well-being.

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Correct Answer is C

Explanation

Rationale

A. Granola and strawberries may be high in fiber, which could potentially worsen diarrhea in some individuals. Tea is generally fine, but it should be non-caffeinated to avoid further irritation to the digestive system.

B. Whole wheat toast can be a good option as it provides carbohydrates for energy without being too heavy. However, coffee is caffeinated and can stimulate bowel movements and increase gastric acid secretion, potentially aggravating diarrhea.

C. Oatmeal is gentle on the stomach and provides soluble fiber, which can help absorb water and bulk up stools. Banana is a good source of potassium, which may be lost during episodes of diarrhea. Herbal tea is non-caffeinated and can help hydrate.

D. Sausage and milk can be high in fat and lactose, which may be difficult to digest, especially during diarrhea. Poached eggs are generally well tolerated, but the overall combination may not be ideal for someone with diarrhea.

A. Assess for symmetrical chest movement.<br> B. Auscultate for presence of bilateral breath sounds. C. Obtain a portable chest x-ray to verify ETT location. D. Monitor ETT markings between 22 and 26 cm at teeth line. E. Check for capillary refill of 3 seconds or less.

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

Explanation

Rationale

A. This involves visually inspecting the chest to ensure both sides rise and fall equally during ventilation. Symmetrical chest movement suggests that both lungs are being adequately ventilated.

B. Auscultation involves listening with a stethoscope over the chest to confirm the presence of breath sounds in both lung fields. Bilateral breath sounds indicate that the ETT is correctly positioned in the trachea, allowing air to reach both lungs.

C. A chest x-ray provides a definitive confirmation of the ETT placement in relation to the trachea and lungs. It allows visualization of the tube's position relative to anatomical landmarks, such as the carina, which helps ensure proper placement.

This involves checking the markings on the ETT tube to ensure it is inserted to the correct depth. Typically, the ETT should be positioned with its tip approximately 2 to 4 cm above the carina, which corresponds to the 22-26 cm mark at the teeth line in adults. However, it does not confirm correct placement.

E. Capillary refill is a measure of peripheral perfusion and is unrelated to ETT placement. It assesses circulatory status by pressing on a nail bed and observing the time it takes for color to return. It does not provide information about ETT placement.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which breakfast selection should the nurse recommend for a 16-year-old with diarrhea?

Correct Answer is C

Explanation

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

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

Explanation

Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

Exhibits Click to specify which client statement or behaviors is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one response selected.

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and tie me up." Which approach should the nurse use with the client?