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 ["A","B","D","G","H"]

Explanation

A. Assessing temperature is important to monitor for any signs of infection or inflammation, which could exacerbate the asthma condition or indicate a concurrent illness.
B. Evaluating breath sounds helps determine the effectiveness of the albuterol treatment in relieving bronchospasm. Clearer breath sounds suggest improved air entry and reduced wheezing.
C. While CBC can provide valuable information, it is not typically immediately necessary after an albuterol treatment unless there are specific concerns about infection or other systemic issues.
D. Monitoring the heart rate is crucial as albuterol can cause tachycardia (elevated heart rate) as a side effect. It's important to ensure that the heart rate does not become excessively elevated, which may indicate a need to adjust treatment or monitor more closely.
E. Peak inspiratory flow is less commonly used in asthma management compared to peak expiratory flow. It's the maximum flow rate during inhalation and is not typically assessed routinely in the immediate post-treatment period.
F. Assessing serum sodium is not directly related to monitoring asthma exacerbation or response to bronchodilator therapy.
G. PEF measures the maximum speed at which a person can exhale air after a deep breath. It is a direct indicator of lung function and the severity of airway obstruction in asthma. Assessing PEF post-albuterol treatment helps gauge how well the airways have responded to the bronchodilator therapy.
H. Checking oxygen saturation ensures that the patient's oxygen levels have improved following the administration of albuterol. The goal is to maintain oxygen saturation above 94%, as per the treatment plan.

A. Take prescribed cortisone accurately.<br> B. Increase daily intake of sodium in diet. C. Avoid extreme environmental temperatures. D. Use a walker when weakness occurs

Correct Answer is C

Explanation

Rationale

A. It's crucial for the client to adhere strictly to the prescribed dosage and schedule to maximize therapeutic benefits and minimize potential side effects. However, temperature regulation is priority

B. Celiac disease requires strict adherence to a gluten-free diet to prevent intestinal damage, while multiple sclerosis management may involve dietary strategies to manage symptoms like fatigue or bladder dysfunction. However, increasing sodium intake generally is not a primary concern unless there are specific indications related to multiple sclerosis symptoms or medication effects.

C. Temperature sensitivity is common in multiple sclerosis, and exposure to extreme heat or cold can exacerbate symptoms such as fatigue, weakness, and cognitive dysfunction. Managing environmental temperature exposure is crucial to minimizing symptom exacerbation and maintaining comfort and safety.

D. Mobility aids, such as walkers, can assist individuals with multiple sclerosis during periods of weakness or impaired balance. Using a walker appropriately can help prevent falls and promote safe mobility. However, this instruction may be more specific to managing symptoms of multiple sclerosis rather than addressing the complex dietary needs associated with celiac disease.

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Naxlex Comprehensive Predictor Exams

Exhibits The nurse starts the albuterol nebulizer as prescribed. Which should the nurse assess after the albuterol nebulizer treatment is complete? Select all that apply.

Correct Answer is ["A","B","D","G","H"]

Explanation

The nurse is preparing for discharge a client with a history of celiac disease who now has developed multiple sclerosis. Which instruction is most important for the nurse to include in the discharge teaching plan?

Correct Answer is C

Explanation

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?

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

The nurse observes that a client with ascites is dyspneic. Which action should the nurse implement first?

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. Which source of contamination should the nurse consider when interviewing the client about exposure?

The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Exhibits Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?