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 B
Explanation
Choice B is correct because anxiety is the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Anxiety is a feeling of fear, nervousness, or apprehension that can interfere with coping and decision making. The nurse should assess the level and source of anxiety and provide emotional support and reassurance to the client. The nurse should also review the pain management techniques and explain the benefits and risks of different analgesic options.
Choice A is incorrect because knowledge deficit is not the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Knowledge deficit is a lack of information or understanding about a topic or situation that can affect learning and behavior. The nurse should evaluate the client's learning needs and provide appropriate education and resources, but this is not as urgent as addressing the client's anxiety.
Choice C is incorrect because pain intolerance is not the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Pain intolerance is an inability or unwillingness to endure pain that can affect quality of life and recovery. The nurse should assess the client's pain level and response to analgesics and adjust the pain management plan accordingly, but this is not as urgent as addressing the client's anxiety.
Choice D is incorrect because anticipatory grieving is not the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Anticipatory grieving is a process of mourning that occurs before an expected loss or death that can affect emotional and physical well-being. The nurse should acknowledge the client's feelings and provide empathy and support, but this is not as urgent as addressing the client's anxiety.
Correct Answer is D
Explanation
Choice A reason: Quiet, calm surroundings are not a specific environmental factor for osteomalacia, which is a condition that causes softening and weakening of the bones due to vitamin D deficiency. However, they may be beneficial for promoting rest and comfort for the client.
Choice B reason: Stimulating sounds and activity are not a specific environmental factor for osteomalacia, which is a condition that causes softening and weakening of the bones due to vitamin D deficiency. However, they may be helpful for enhancing mood and cognition for the client.
Choice C reason: Cool, moist air is not a specific environmental factor for osteomalacia, which is a condition that causes softening and weakening of the bones due to vitamin D deficiency. However, it may be preferable for preventing dehydration and overheating for the client.
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