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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A

Providing pamphlets about heart-healthy diet selections should not be implemented. Providing information is important, but it might not be as effective if the client is strongly resistant. Engaging in a conversation first can help tailor the information to the client's needs.

Choice B

Referring the client to a dietitian for nutrition education should not be implemented. A dietitian can provide valuable education, but it might be more beneficial to address the client's concerns and resistance before making the referral.

Choice C

Discussing client's concerns about the change in diet should be implemented. When a client is resistant or unwilling to make changes to their diet and lifestyle, it's important for the nurse to engage in open and empathetic communication. Option C, discussing the client's concerns about the change in diet, is the most appropriate initial response.

By engaging in a conversation with the client, the nurse can better understand the client's perspective, reasons for resistance, and potential barriers to making dietary changes. This approach allows the nurse to address the client's concerns, provide information, and work collaboratively to find solutions that might be more acceptable to the client.

Choice D

Suggesting exercise as an alternative to increase HDL levels should not be implemented. Exercise is important for heart health, but it's important to address the client's resistance to dietary changes first. Additionally, dietary changes and exercise can work together to improve overall heart health.

A. Advise the client that too much fruit can irritate the colon. B. Inform the client that oatmeal contains gluten. C. Commend the client for selecting fat free milk. D. Encourage the client to choose decaffeinated coffee.

Correct Answer is B

Explanation

Choice A

Advising the client that too much fruit can irritate the colon is not the right choice. While it's true that excessive consumption of certain fruits can cause gastrointestinal discomfort, this information is not directly related to celiac disease or the selected meal.

Choice B

Informing the client that oatmeal contains gluten is the right choice. Celiac disease is an autoimmune disorder in which consuming gluten, a protein found in wheat, rye, and barley, triggers an immune response that damages the small intestine. Oatmeal itself is naturally gluten-free, but it is often processed in facilities that also process gluten-containing grains, which can lead to cross-contamination. Therefore, it's important for individuals with celiac disease to choose certified gluten-free oats to avoid adverse reactions.

Choice C

Commending the client for selecting fat-free milk is not the best choice. While choosing a healthier milk option is beneficial for overall health, it is not the most important action in this situation, considering the client's celiac disease.

Choice D reason;

Encouraging the client to choose decaffeinated coffee is not the right choice. The choice of caffeinated or decaffeinated coffee is a matter of preference and is not directly related to celiac disease or the potential for gluten exposure from the oatmeal.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client with celiac disease selects a bowl of oatmeal with fresh fruit and skim milk, grapefruit juice, and coffee from the breakfast menu. Which action is most important for the nurse to implement?

Correct Answer is B

Explanation

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