The nurse is caring for an older adult client that is exhibiting signs of confusion. Which intervention should the nurse implement?

Choice B reason:

Reviewing the intake and output record is essential for identifying potential causes of the client’s confusion, such as dehydration or electrolyte imbalances. Monitoring fluid intake and output helps assess the client’s hydration status and detect any imbalances that could contribute to confusion. This intervention allows the nurse to make informed decisions about fluid and electrolyte management to address the underlying cause of the confusion.

Choice A reason:

Offering water to the client hourly can help maintain hydration but may not be sufficient if the client has an underlying condition affecting fluid balance. It is important to first assess the client’s overall fluid status through intake and output records before implementing hydration strategies.

Choice C reason:

Reducing dairy product intake is not directly related to addressing confusion. Unless the client has a specific intolerance or allergy to dairy, this intervention is unlikely to impact their cognitive status.

Choice D reason:

Increasing daily sodium intake can be harmful if the client does not have a sodium deficiency. Excess sodium can lead to fluid retention and exacerbate confusion, especially in older adults. It is important to assess the client’s electrolyte levels before making any changes to sodium intake.

Choice D reason:

Reviewing the client’s history for a dairy allergy is the most important step before starting whey protein concentrate because whey is derived from milk. If the client has a dairy allergy, consuming whey protein could cause severe allergic reactions, including anaphylaxis. Ensuring the client does not have a dairy allergy is crucial for their safety and to prevent any adverse health effects. This step is essential to determine if whey protein is a suitable and safe option for the client.

Choice A reason:

Checking the client’s cholesterol level is important for overall health management, especially in obese clients. However, it is not the most critical factor when considering the safety of whey protein concentrate. The primary concern should be ensuring the client can safely consume the protein without allergic reactions.

Choice B reason:

Assessing the client’s motivation for change is important for long-term success in weight management and dietary changes. However, it does not directly impact the immediate safety of starting whey protein concentrate. The focus should be on identifying any potential allergies that could cause harm.

Choice C reason:

Reviewing the client’s history of hypertension is important for managing their overall health. However, it is not the most critical factor in determining the safety of whey protein concentrate. The primary concern should be ensuring the client does not have a dairy allergy, which could lead to severe allergic reactions.