The nurse is caring for an older client with that is exhibiting signs of confusion. Which intervention should the nurse implement?
Offer water to the client hourly.
Reduce dairy product intake.
Increase daily sodium intake.
Review the intake and output record.
The Correct Answer is D
Choice A
Offering water to the client hourly is not appropriate. While staying hydrated is important for overall health, offering water hourly might not be necessary unless there is a specific indication of dehydration. However, monitoring the client's fluid intake and output is a good approach.
Choice B
Reducing dairy product intake is not appropriate. Dairy product intake is not typically associated with sudden onset confusion. Reducing dairy product intake would not be the primary intervention for addressing confusion.
Choice C
Increasing daily sodium intake is not appropriate. Increasing sodium intake is unlikely to be the appropriate intervention for confusion unless there is a specific medical reason for it. Moreover, excessive sodium intake can have negative health consequences.
Choice D
Reviewing the intake and output record is appropriate. Confusion in an older client can be caused by various factors, including medical conditions, medication side effects, dehydration, and electrolyte imbalances. Reviewing the intake and output record (option D) is a reasonable intervention to gather more information about the client's fluid balance and hydration status. This can help the nurse assess whether the confusion might be related to dehydration or electrolyte imbalances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A
Counting carbohydrates will ensure glucose levels stay within a normal range is accurate. When providing dietary education to a client with Type 2 diabetes mellitus, it's important to emphasize the role of carbohydrate counting in managing blood glucose levels. Carbohydrate intake significantly impacts blood sugar levels, and counting carbohydrates can help the client make informed decisions about their meals and medications to maintain glucose levels within a normal range.
Choice B
Many carbohydrates are found in starches and fruits is not accurate. Carbohydrates are present in a variety of foods, including starches (such as bread, rice, and pasta) but not fruits. Educating the client about sources of carbohydrates can help them make choices that support blood sugar management.
Choice C
It is best to count carbohydrates when it feels like blood glucose is low is not accurate. Counting carbohydrates is an ongoing practice that helps individuals with diabetes maintain consistent blood sugar levels throughout the day, not just when blood glucose feels low.
Choice D
Examples of complex carbohydrates are white rice and cereals is inaccurate. White rice and many cereals are actually exampling of simple carbohydrates. Complex carbohydrates include foods like whole grains, legumes, and vegetables. It's important to provide accurate information about carbohydrate types.
Correct Answer is B
Explanation
Choice A
Client with a nasogastric tube to low, intermittent suction is not correct. While there is a risk of aspiration with a nasogastric tube in place, the tube is intended to help drain stomach contents, reducing the risk of aspiration. However, if the tube is not properly positioned or managed, there could still be some risk.
Choice B
Client who has sensory aphasia and is receiving a clear liquid diet is correct. Sensory aphasia refers to a language disorder that affects a person's ability to understand language and communication. This client may have difficulty swallowing safely and effectively, which increases the risk of aspiration. Additionally, a clear liquid diet consists of thin liquids that are more likely to be aspirated compared to thicker fluids.
Choice C
Client receiving 30% oxygen via a non-rebreather face mask is not correct. Oxygen therapy can increase the risk of drying the airways and potentially increasing the risk of aspiration, but if the oxygen mask is properly fitted and humidified, the risk may be minimized.
Choice D
Client experiencing dysphagia who is prescribed a full liquid diet is not correct. Dysphagia refers to difficulty swallowing, which can increase the risk of aspiration. However, a full liquid diet includes thicker liquids that are less likely to be aspirated compared to thin liquids. Still, the risk of aspiration exists, especially if the client has severe dysphagia.
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