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 C
Explanation
Choice A: 18%. This is not the correct percentage, as it only accounts for one lower extremity. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so both lower extremities would account for 18% x 2 = 36%.
Choice B: 27%. This is not the correct percentage, as it only accounts for one and a half lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so one and a half lower extremities would account for 9% x 3 = 27%.
Choice C: 36%. This is the correct percentage, as it accounts for both lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so both lower extremities would account for 9% x 4 = 36%.
Choice D: 45%. This is not the correct percentage, as it accounts for more than both lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so more than both lower extremities would account for more than 9% x 4 = 36%.
Correct Answer is C
Explanation
Choice A: Monitoring indwelling urinary catheter and measure strict intake and output is not an action that the nurse should immediately take, as this is not relevant or urgent for a client who may have had a stroke. This is a distractor choice.
Choice B: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an action that the nurse should immediately take, as this is a preventive measure that does not address the acute problem of impaired cerebral perfusion. This is another distractor choice.
Choice C: Starting two large bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is an action that the nurse should immediately take, as this can prepare the client for potential administration of tissue plasminogen activator (tPA., which can dissolve blood clots and restore blood flow to the brain if given within 4.5 hours of stroke onset. Therefore, this is the correct choice.
Choice D: Maintaining elevated positioning of the dependent joints on affected side is not an action that the nurse should immediately take, as this can worsen edema and impair circulation in the affected limbs. The recommended position is to keep them at or below heart level. This is another distractor choice.
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