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
Demonstrating correct measurement of the tube insertion length is the first priority. Inserting a nasogastric tube to the appropriate length is crucial for ensuring that the tube reaches the stomach and is not inserted too far. Incorrect insertion length can lead to complications, discomfort, or potential harm to the patient. Therefore, demonstrating and ensuring the correct measurement of the tube insertion length takes priority.:
Choice B
Reminding the nurse to apply lubricant to the tube before insertion is not first priority. Applying lubricant helps ease the insertion process, but it is not the most critical step to prioritize initially.
Choice C
Confirming that the nurse has auscultated the client's bowel sounds is not the first priority. Bowel sounds assessment is important to ensure proper placement, but this step can be done after ensuring the correct measurement of the insertion length.
Choice D
Elevating the head of the bed before the nurse inserts the tube is not the first priority: Elevating the head of the bed helps facilitate the passage of the tube into the stomach, but it is not the first priority in this context.
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.
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