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

Answer and Explanation

Correct Answer : A,B,D,E

A. Confusion can be a sign of a concussion or other injury resulting from a fall, which is a common risk for individuals with Parkinson's disease.
B. Reviewing the client's current food and medication allergies is important as allergies can contribute to confusion if the client is exposed to an allergen.
C. Encouraging increased intake of high protein foods is generally recommended for individuals with Parkinson's disease, but it is not directly related to the acute onset of confusion.
D. Checking the mother's temperature is a direct action to assess for infection, which can be a cause of acute confusion, especially in older adults.
E. Pain with urination could indicate a urinary tract infection, which is another common cause of confusion in the elderly. It is important to assess for this possibility.

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Correct Answer is C

Explanation

A: An adolescent with multiple contusions due to a fall that occurred 2 days ago can be managed by the PN as the condition is stable and does not require the advanced skills of an RN.
B: A 75-year-old client with renal calculi who requires urine straining can also be assigned to the PN because urine straining is a task within the PN's scope of practice.
C: A 30-year-old depressed client who admits to suicide ideation requires the expertise of an RN due to the need for continuous assessment, potential for crisis intervention, and the complexity of care needed.
D: A 64-year-old client who had a total hip replacement the previous day would typically be stable post-operation and could be managed by the PN, with the RN available for any complications that may arise.

A. An adult client with a rectal tube draining clear, pale red liquid drainage. B. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac. C. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed. D. An older client with a distended abdomen and no drainage from the nasogastric tube.

Correct Answer is C

Explanation

A. The presence of clear, pale red liquid drainage from the rectal tube suggests possible bleeding or other issues that need prompt assessment, making this client a priority.

B. Dark red drainage on a postoperative dressing could indicate bleeding, which requires immediate attention to assess the extent of bleeding and intervene accordingly.

C. Clients with compressed Jackson-Pratt drains may not have adequate drainage, potentially leading to complications such as hematoma or infection if the drain becomes obstructed.

However, since the bulb is compressed, indicating no active drainage, this client can be assessed later.

D. A distended abdomen with no drainage from the nasogastric tube could indicate a bowel obstruction or other gastrointestinal issue requiring urgent assessment, making this client a priority for assessment.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?

Correct Answer is C

Explanation

After receiving report, the nurse can most safely plan to assess which client last?

Correct Answer is C

Explanation

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