An older male client who is admitted to a rehabilitation facility manifests signs of acute dementia. The nurse observes the client repeatedly calling out for his deceased spouse to come and get him. Which intervention(s) should the nurse implement? Select all that apply.

Reorient the client while performing assessment.

Lower the lighting in the client's room.

Switch to a familiar topic after acknowledging client's feelings.

Remind the client that his spouse is deceased.

Explain the rehabilitation regimen to the client.

Answer and Explanation

Correct Answer : B,C

A. Reorient the client while performing assessment: Reorienting a client with acute dementia during periods of distress can increase confusion and agitation. Forcing orientation is often counterproductive and may escalate anxiety.

B. Lower the lighting in the client's room: Reducing harsh lighting can help decrease overstimulation and agitation, creating a calmer environment for a client experiencing acute confusion or distress.

C. Switch to a familiar topic after acknowledging client's feelings: Validating the client’s emotions and then gently redirecting to familiar topics can reduce anxiety, provide comfort, and improve cooperation without causing confrontation.

D. Remind the client that his spouse is deceased: Confronting the client with reality in a distressed state can increase agitation, fear, and confusion. Reality orientation should be approached cautiously, if at all, during acute episodes.

E. Explain the rehabilitation regimen to the client: While education about care is generally important, a client in acute dementia may not be able to process detailed explanations. This intervention does not address immediate emotional distress or safety.

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Correct Answer is []

Explanation

• Nephrotic syndrome: The child’s rapid weight gain over two months, generalized edema, fatigue with minimal activity, and laboratory findings showing significant proteinuria, hypoalbuminemia, and mild hematuria strongly suggest nephrotic syndrome, which involves increased glomerular permeability and fluid retention.

• Administering intravenous albumin increases plasma oncotic pressure, helping to pull interstitial fluid back into the intravascular space, thereby reducing edema, improving circulatory volume, and supporting perfusion in a child with hypoalbuminemia.

• Provide a low-salt diet: Implementing a low-sodium diet is essential to help manage fluid retention associated with nephrotic syndrome, as excessive sodium intake worsens edema and may contribute to hypertension and further fluid overload.

• Daily weight: Monitoring daily weight provides a sensitive measure of fluid status and the effectiveness of therapeutic interventions, as even small changes in weight can reflect shifts in edema or fluid accumulation.

• Abdominal girth: Measuring abdominal girth regularly allows the nurse to track ascites and fluid accumulation in the peritoneal cavity, which is a common complication of nephrotic syndrome and can indicate worsening disease or inadequate response to therapy.

Rationale for Incorrect Choices:

• Type 1 diabetes: Type 1 diabetes typically presents with hyperglycemia, polyuria, polydipsia, and weight loss, none of which are observed in this child. The presence of edema and proteinuria is not consistent with diabetes.

• Hemolytic uremic syndrome: HUS is characterized by acute kidney injury, microangiopathic hemolytic anemia, and thrombocytopenia. This child does not exhibit hemolysis, platelet abnormalities, or acute renal failure, making HUS unlikely.

• Wilms' tumor: Wilms’ tumor usually presents as a palpable abdominal mass, sometimes with hematuria, but it does not cause generalized edema, proteinuria, or hypoalbuminemia, which are prominent in this child.

• Place the child on strict bed rest: Strict bed rest is unnecessary unless the child’s symptoms are severe. Children with nephrotic syndrome can maintain normal activity levels while under medical monitoring.

• Prepare the child for emergency surgery: Nephrotic syndrome is a medical condition requiring pharmacologic and dietary management, not surgical intervention; surgery is not indicated in this scenario.

• Prepare an insulin drip: There is no evidence of hyperglycemia, ketosis, or diabetes in this child, so initiating an insulin drip would be inappropriate and unrelated to the presenting condition.

• Lymph node size: Lymphadenopathy is not a feature of nephrotic syndrome, and changes in lymph node size would not provide useful information for monitoring this child’s condition or treatment response.

• Ketones: Ketone monitoring is relevant for patients with diabetes or fasting states but is not necessary in nephrotic syndrome, as ketonuria is not a feature of this disease.

• Bladder volume: Bladder monitoring is not required because there is no evidence of urinary obstruction or retention; fluid balance is better assessed by weight and urine output rather than bladder volume.

A. Palpate and compare radial pulses. B. Administer ondansetron 4 mg IV. C. Perform range of motion. D. Provide morphine 2 mg IV push (IVP). E. Inspect the bandage for drainage. F. Check capillary refill on bilateral upper extremities.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

• Palpate and compare radial pulses: Assessing radial pulses bilaterally is essential after humeral fracture and surgical repair because neurovascular compromise is a major complication. Detecting differences in pulse quality can help identify impaired circulation or compartment syndrome early.

• Administer ondansetron 4 mg IV: The client reports nausea postoperatively, which can increase discomfort and risk for aspiration. Ondansetron is prescribed and effective in controlling nausea by blocking serotonin receptors in the gut and brain, making it an appropriate intervention.

• Perform range of motion: With a displaced humeral head/neck fracture and immediate postoperative status, range-of-motion exercises are contraindicated. Movement of the joint could disrupt fixation, increase bleeding, or worsen pain. Immobilization and stabilization are priorities.

• Provide morphine 2 mg IV push (IVP): The client has a prescription for morphine for severe pain, and his reported pain was previously 10/10 before surgery. Administering morphine is indicated to ensure adequate pain control, prevent sympathetic stress responses, and promote rest and healing.

• Inspect the bandage for drainage: Checking the surgical bandage is necessary to monitor for bleeding or excessive drainage, which may indicate complications such as hemorrhage or infection. Since the order specifies not to remove the dressing, visual inspection only is the correct approach.

• Check capillary refill on bilateral upper extremities: Capillary refill helps evaluate peripheral perfusion, which is critical after orthopedic surgery. Comparing both extremities provides baseline data and helps detect vascular compromise that could threaten limb viability.

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An older male client who is admitted to a rehabilitation facility manifests signs of acute dementia. The nurse observes the client repeatedly calling out for his deceased spouse to come and get him. Which intervention(s) should the nurse implement? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

Patient Data Exhibits The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

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