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","B","D"]
Explanation
Choice A reason: This is a correct answer because flushing the tube with more water is important to prevent clogging and maintain hydration. The novice should flush the tube with at least 15 mL of water before and after each medication, and between medications if more than one is given.
Choice B reason: This is a correct answer because administering each medication separately is important to prevent interactions and ensure accurate dosing. The novice should not mix different medications in one syringe or container, but give them one at a time, followed by water flushes.
Choice C reason: This is not a correct answer because adding the liquid volumes when documenting fluid intake is not necessary. The liquid medications do not count as fluid intake, but as medication administration. The novice should document the type, dose, route, and time of each medication given, as well as any adverse effects or complications.
Choice D reason: This is a correct answer because confirming that the novice determined the amount of gastric residual is important to assess tolerance and prevent aspiration. The novice should aspirate the gastric contents with a syringe before giving any medication or feeding, and measure and document the volume. If the volume is more than 100 mL or the prescribed amount, the novice should hold the medication or feeding and notify the healthcare provider.
Choice E reason: This is not a correct answer because advising the novice to use the plunger when giving medications is not recommended. The novice should use gravity to deliver the medications through the tube, by holding the syringe upright and allowing the liquid to flow slowly. Using the plunger can cause too much pressure and damage the tube or cause discomfort to the client.
Correct Answer is C
Explanation
Choice A reason: Providing bedside equipment for transmission and protective precautions is not the first action that the nurse should implement, as this is a standard precaution that should be already in place for all clients in the critical care unit. This is a distractor choice.
Choice B reason: Evaluating daily serum electrolytes and hydration status is not the first action that the nurse should implement, as this is a routine assessment that can be done later after addressing the immediate problem of infection. This is another distractor choice.
Choice C reason: Culturing sputum, urine, burn wound, and all intravenous access sites is the first action that the nurse should implement, as this can help identify the source and type of infection, which can guide the appropriate antibiotic therapy and prevent further complications. Therefore, this is the correct choice.
Choice D reason: Implementing central line-associated bloodstream infection (CLABSI) protocols is not the first action that the nurse should implement, as this is a preventive measure that may not be applicable for this client who already has SIRS. This is another distractor choice.
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