The nurse is caring for an older adult client who has an infection and a fever of 38°C (100.4°F).
The nurse should monitor the client for which of the following complications?
Dehydration
Hypothermia
Seizures
Delirium
The Correct Answer is D
The correct answer is D.
Delirium.
The nurse should monitor the client for delirium, which is a state of acute mental confusion that can be caused by fever, infection, dehydration, or medications.
Delirium can affect the client’s cognition, attention, orientation, memory, and behavior. It can also increase the risk of falls, complications, and mortality.
Choice A is wrong because dehydration is not a complication of fever, but rather a possible cause of fever.
Dehydration occurs when the body loses more fluid than it takes in, and it can impair the body’s ability to regulate its temperature. Dehydration is more common and dangerous in older adults because they have a lower volume of water in their bodies, a weaker thirst response, and may have conditions or medications that increase fluid loss.
Choice B is wrong because hypothermia is not a complication of fever, but rather a condition of abnormally low body temperature.
Hypothermia can occur when the body loses heat faster than it can produce it, such as in cold weather or water exposure. Hypothermia can affect the brain, heart, and other organs, and can lead to death if not treated promptly.
Choice C is wrong because seizures are not a common complication of fever in older adults.
Seizures are sudden episodes of abnormal electrical activity in the brain that can cause changes in movement, sensation, behavior, or consciousness.
Seizures can have various causes, such as head injury, stroke, infection, or epilepsy.
Fever-induced seizures are more likely to occur in young children than in older adults.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C.
Ego integrity vs despair.
According to Erikson’s psychosocial theory, older adults face the challenge of looking back on their lives and evaluating their accomplishments and failures.
If they feel satisfied with their life course, they achieve a sense of ego integrity, which is a feeling of wholeness and coherence.
If they feel regretful or dissatisfied, they experience despair, which is a sense of hopelessness and bitterness.
Choice A is wrong because trust vs mistrust is the first stage of Erikson’s theory, which occurs in infancy.
It involves developing a basic sense of trust in oneself and others based on the quality of caregiving.
Choice B is wrong because generativity vs stagnation is the seventh stage of Erikson’s theory, which occurs in middle adulthood.
It involves contributing to society and the next generation through work, parenting, or other activities.
Choice D is wrong because identity vs role confusion is the fifth stage of Erikson’s theory, which occurs in adolescence.
It involves developing a stable and coherent sense of self and one’s role in society.
Normal ranges for Erikson’s stages are:.
• Trust vs mistrust: birth to 18 months.
• Autonomy vs shame and doubt: 18 months to 3 years.
• Initiative vs guilt: 3 to 6 years.
• Industry vs inferiority: 6 to 12 years.
• Identity vs role confusion: 12 to 18 years.
• Intimacy vs isolation: 18 to 40 years.
• Generativity vs stagnation: 40 to 65 years.
• Ego integrity vs despair: 65 years and older.
Correct Answer is B
Explanation
Intention tremors and nystagmus.These are some of the common symptoms of multiple sclerosis (MS), a condition that affects the central nervous system and causes communication problems between the brain and the rest of the body.Intention tremors are involuntary shaking movements that occur when a person tries to perform a precise action, such as reaching for an object or writing.Nystagmus is a condition where the eyes make repetitive, uncontrolled movements, often resulting in reduced vision and depth perception.
Choice A is wrong because muscle atrophy and fasciculations are more typical of motor neuron diseases, such as amyotrophic lateral sclerosis (ALS), which affect the nerve cells that control voluntary muscle movements.
Choice C is wrong because flaccid paralysis and areflexia are signs of lower motor neuron lesions, which can be caused by spinal cord injuries, peripheral nerve disorders, or Guillain-Barré syndrome.
Choice D is wrong because hyperactive reflexes and spasticity are signs of upper motor neuron lesions, which can be caused by stroke, traumatic brain injury, or cerebral palsy.
Normal ranges for some of the symptoms mentioned are:.
• Intention tremors: none or minimal.
• Nystagmus: none or minimal.
• Muscle atrophy: none or minimal.
• Fasciculations: none or minimal.
• Flaccid paralysis: none or minimal.
• Areflexia: absent or reduced reflexes.
• Hyperactive reflexes: normal or slightly increased reflexes.
• Spasticity: normal or slightly increased muscle tone.
A. Muscle atrophy and fasciculations B.
Intention tremors and nystagmus C.
Flaccid paralysis and areflexia D.
Hyperactive reflexes and spasticity
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