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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale

A. This intervention is crucial because bariatric surgery can have significant psychological impacts. Many individuals who undergo such procedures may experience changes in mood, body image issues, and emotional challenges. However, it is not a priority

B. Sequential compression stockings are used to prevent deep vein thrombosis (DVT) and promote circulation in clients undergoing surgery, particularly those with obesity who are at higher risk for venous thromboembolism. This intervention is important to prevent serious complications associated with immobility and surgery.

C. This option is not appropriate immediately after gastroplasty. Bariatric surgery, such as gastroplasty, typically involves restrictive procedures that limit the amount of food a person can consume. Providing a wide variety of meal choices contradicts the dietary restrictions and guidelines that are crucial for successful outcomes post-surgery.

D. While urinary incontinence can be a concern in some individuals, it is not directly related to bariatric surgery or the client's primary health concerns of obesity, diabetes mellitus, and hypertension. Monitoring for urinary incontinence may be important in other clinical contexts but is not a priority in the immediate postoperative period of gastroplasty.

A. "I can learn to manage my thoughts better through therapy." B. "This diagnosis means that I am crazy." C. "Many people have the same response to a stressful situation as I am having right now." D. "I can use holistic approaches like meditation to help my symptoms." E. "I will probably need to be on medication for the rest of my life." F. "I am at high risk for post-traumatic stress disorder because I have acute stress disorder."

Correct Answer is ["B","E","F"]

Explanation

B. This statement suggests a misunderstanding or stigma associated with mental health diagnoses. It's important for the nurse to clarify that experiencing acute stress disorder or any other psychological response to trauma does not equate to being "crazy." This can help reduce stigma and promote understanding that such responses are normal reactions to abnormal situations.
E. This statement indicates a potential misunderstanding about the duration of medication use. Clonazepam, in this case, is prescribed to manage acute symptoms related to anxiety and sleep disturbance. The nurse should explain that medication use for psychological symptoms is typically temporary and part of a broader treatment plan that may include therapy and other interventions aimed at recovery and long-term well-being.
F. While acute stress disorder is a risk factor for developing post-traumatic stress disorder (PTSD), not everyone who experiences acute stress disorder will develop PTSD. It's important for the nurse to provide education about the differences between acute stress disorder and PTSD, their symptoms, and the importance of ongoing monitoring and support to prevent long-term psychological difficulties.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Exhibits Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

Correct Answer is ["B","E","F"]

Explanation

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?

Exhibits Select from the options to complete the sentence. After listening to the client's symptoms, the nurse realizes that she likely has dropdown related to dropdown

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