The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.

Determine if the client has recently experienced a fall.

Instruct the adult child to check the client's temperature.

Ask if the client is experiencing any pain with urination.

Encourage increased intake of high protein foods.

Review the client's current food and medication allergies.

Answer and Explanation

Correct Answer : A,B,C,E

A.   Falls can lead to head injuries or subdural hematomas, which can cause confusion in older adults. It is important to assess for recent trauma as a possible cause of the confusion.
B.   An elevated temperature can indicate an infection, such as a urinary tract infection (UTI) or pneumonia, which are common causes of acute confusion in older adults.
C.   Pain with urination is a symptom of a UTI, which can lead to confusion, especially in elderly patients with Parkinson's disease.
D.   While maintaining adequate nutrition is important, increasing protein intake does not directly address the sudden onset of confusion.
E.   New medications or allergic reactions can lead to confusion. A medication interaction or an allergic reaction to a new food could be a contributing factor.

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Correct Answer is C

Explanation

A. Suggesting the antecubital site does not address the immediate issue of using an inappropriate needle size.
B. Sending a UAP to gather equipment is not an immediate action needed to correct the mistake.
C. Using an 18-gauge needle to irrigate an IV catheter is inappropriate and could damage the catheter. The charge nurse should instruct the new nurse to remove the needle and use a syringe without a needle to perform the irrigation safely.
D. Starting a secondary infusion is unrelated to the irrigation process and does not correct the inappropriate needle use.

A. Chew food slowly and thoroughly before attempting to swallow. B. Sip fluids slowly with each meal and between meals. C. Eliminate or reduce intake of fatty and gas forming foods. D. Plan volume-controlled, evenly-spaced meals throughout the day.

Correct Answer is D

Explanation

A. While chewing food well is important to aid digestion and prevent discomfort, meal timing and portion control are the primary concerns in gastric bypass patients.

B. Sipping fluids slowly is important, but fluids should generally be taken between meals rather than with meals to prevent stretching the stomach pouch and to avoid dumping syndrome.
C. Reducing fatty and gas-forming foods can help avoid discomfort, but this is less critical than ensuring proper food breakdown through thorough chewing.
D. After gastric bypass surgery, small, frequent meals help prevent dumping syndrome, a condition in which food moves too quickly from the stomach to the small intestine, causing nausea, dizziness, and diarrhea. Portion control is essential to avoid overstretching the reduced stomach pouch and ensure adequate nutrient absorption.

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The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching an 18-gauge needle. Which action should the charge nurse take?

Correct Answer is C

Explanation

A client who underwent an uncomplicated gastric bypass surgery is having difficulty with diet management. Which dietary instruction is most important for the nurse to explain to the client?

Correct Answer is D

Explanation

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