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 B
Explanation
Choice A
Potatoes are incorrect. Potatoes are high in carbohydrates and can cause a rapid increase in blood sugar levels, so they are not the best choice for someone with diabetes trying to avoid refined sugars and carbs.
Choice B
Avocado is correct. Avocado is a good choice for someone with Type 2 diabetes who wants to avoid refined sugars and carbohydrates. Avocado is a healthy source of monounsaturated fats, fibre, and various vitamins and minerals. It has a low glycaemic index and doesn't significantly raise blood sugar levels, making it a suitable option for people with diabetes.
Choice C
Grapes is incorrect: Grapes are a fruit with natural sugars, and although they contain fibre, they can still cause spikes in blood sugar levels.
Choice D
Pretzels are incorrect. Pretzels are usually made from refined flour and are high in simple carbohydrates, causing rapid spikes in blood sugar levels. They are not a good choice for someone with diabetes aiming to avoid refined sugars and carbs.
Correct Answer is B
Explanation
Choice A
Apples and blueberries are incorrect. While apples and blueberries are sources of nutrients, they are not as high in potassium as avocados and bananas.
Choice B
Avocados and bananas are correct. Chronic kidney disease (CKD) often requires dietary modifications to manage electrolyte and mineral imbalances. In CKD stage 4, the kidney's ability to filter waste and excess substances from the blood is significantly impaired. Therefore, certain foods that are high in potassium should be limited to prevent hyperkalaemia (elevated blood potassium levels).
Choice C
Cherries and cranberries are incorrect. Cherries and cranberries are also sources of nutrients, but their potassium content is not as high as that of avocados and bananas.
Choice D
Carrots and green beans are incorrect. Carrots and green beans are vegetables that are generally lower in potassium compared to fruits like avocados and bananas.
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