The daughter of an older woman who has Parkinson's disease, calls the clinic and reports that her mother has been confused for the past week. Which action(s) should the nurse take? (Select all that apply.)
Determine if the mother has recently experienced a fall.
Review the client's current food and medication allergies.
Encourage increased intake of high protein foods.
Instruct the daughter to check her mother's temperature.
Ask if the mother is experiencing any pain with urination.
Correct Answer : A,D,E
Choice A reason: This is a correct answer because determining if the mother has recently experienced a fall is important to rule out any head injury or concussion that could cause confusion. Parkinson's disease can increase the risk of falls due to impaired balance, coordination, and mobility.
Choice B reason: This is not a correct answer because reviewing the client's current food and medication allergies is not relevant to the mother's confusion. However, it may be important to review the client's current medications and dosages to check for any adverse effects or interactions that could affect cognition.
Choice C reason: This is not a correct answer because encouraging increased intake of high protein foods is not helpful for the mother's confusion. In fact, high protein foods may interfere with the absorption of levodopa, a medication used to treat Parkinson's disease symptoms. The nurse should advise the daughter to consult with a dietitian about the optimal timing and amount of protein intake for her mother.
Choice D reason: This is a correct answer because instructing the daughter to check her mother's temperature is important to detect any fever or infection that could cause confusion. Older adults are more susceptible to infections such as urinary tract infections (UTIs), pneumonia, or sepsis, whih can affect mental status.
Choice E reason: This is a correct answer because asking if the mother is experiencing any pain with urination is important to screen for any UTI that could cause confusion. UTIs are common in older adults due to reduced bladder function, incomplete emptying, and decreased immunity. UTIs can cause symptoms such as dysuria, frequency, urgency, hematuria, and delirium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
Choice A reason: Consuming foods with saturated fats can increase the level of low-density lipoprotein (LDL) cholesterol in the blood, which can contribute to plaque formation and narrowing of the coronary arteries.
Choice B reason: Walking 30 minutes per day can help lower blood pressure, improve blood circulation, and reduce the risk of heart attack and stroke.
Choice C reason: Using a salt substitute can help lower sodium intake, which can reduce fluid retention and lower blood pressure.
Choice D reason: Keeping a food diary can help the client monitor their calorie intake, portion size, and nutritional balance.
Choice E reason: Eating more canned vegetables can increase sodium intake, which can worsen fluid retention and blood pressure. Fresh or frozen vegetables are preferable.
Choice F reason: Including oatmeal for breakfast can provide soluble fiber, which can lower LDL cholesterol and prevent plaque formation in the coronary arteries.
Correct Answer is D
Explanation
Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.
Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.
Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.
Choice D reason: This is the correct answer because starting two large bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is a critical action for the nurse to take. IV catheters are devices that allow access to the bloodstream for fluid or medication administration. Fibrinolytic therapy is a treatment that dissolves blood clots that may block blood flow to vital organs, such as the brain or heart. The client's symptoms suggest a possible stroke, which is a medical emergency that occurs when blood flow to a part of the brain is interrupted, causing brain tissue damage or death. The nurse should start two large bore IV catheters in case one fails or becomes occluded, and review inclusion criteria for IV fibrinolytic therapy, such as onset of symptoms, blood pressure, blood glucose, coagulation status, and history of bleeding or trauma, to determine if the client is eligible for this potentially life-saving treatment.
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