The primary caregiver of an elderly patient contacts the nurse at the outpatient clinic due to a sudden change in the patient’s behavior.

The caregiver informs the nurse that the patient, who is usually oriented and able to answer Questions, is now confused and agitated.

What actions should the nurse take? (Select all that apply)

Inquire if the patient is experiencing any pain during urination.

Encourage the patient to increase their intake of high-protein foods.

Review the patient’s current food and medication allergies.

Determine if the patient has recently experienced a fall.

Provide instructions on how to take the patient’s temperature.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale
A sudden change in behavior, especially confusion and agitation, in an elderly patient could be a sign of a urinary tract infection (UTI). Pain during urination is a common symptom of UTIs.
Therefore, it is crucial to inquire if the patient is experiencing any pain during urination.
Choice B rationale

While a high-protein diet can be beneficial for some patients, there is no direct link between increased protein intake and the alleviation of confusion or agitation in elderly patients.
Therefore, this option is not a necessary immediate action for the nurse to take.
Choice C rationale
Reviewing the patient’s current food and medication allergies is important. Certain medications or foods might cause adverse reactions, including confusion and agitation. Therefore, it is crucial to review the patient’s allergies to rule out any potential allergens as the cause of the sudden change in behavior.
Choice D rationale
A recent fall could potentially lead to a head injury, which might cause confusion and agitation. Therefore, it is important to determine if the patient has recently experienced a fall.
Choice E rationale
Providing instructions on how to take the patient’s temperature is important. Fever could be a sign of an infection or other medical condition that might cause confusion and agitation.
Therefore, knowing how to accurately measure the patient’s temperature can help monitor the patient’s condition.

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Correct Answer is A

Explanation

Choice A rationale
Pregabalin is a medication used to treat nerve pain, particularly in conditions like diabetic peripheral neuropathy. A reduced level of pain would indicate that the medication is effective.
Choice B rationale
Improved visual acuity is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect vision.
Choice C rationale
Full volume of pedal pulses is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect circulation.
Choice D rationale
Granulating tissue in a foot ulcer is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect wound healing.

A. Absence of coarse crackles. B. Increase in breath sounds. C. Absence of fine crackles. D. Increase in respiratory rate.

Correct Answer is B

Explanation

Choice A rationale
The absence of coarse crackles is not necessarily an indication that chest physiotherapy (CPT) has been effective for a client with chronic obstructive pulmonary disease (COPD). Coarse crackles are often heard in conditions where there is fluid in the airways, such as pneumonia or heart failure. While their absence might indicate that there is no fluid in the airways, it does not necessarily mean that secretions have been effectively mobilized.
Choice B rationale
An increase in breath sounds is a good indication that chest physiotherapy (CPT) has been effective for a client with COPD3. CPT is a group of therapies designed to improve respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system. When these secretions are effectively mobilized and removed, breath sounds can become clearer and more easily heard.
Choice C rationale

The absence of fine crackles is not necessarily an indication that CPT has been effective for a client with COPD. Fine crackles are often heard in conditions where there is fluid in the airways or alveoli, such as pneumonia or heart failure. While their absence might indicate that there is no fluid in the airways or alveoli, it does not necessarily mean that secretions have been effectively mobilized.
Choice D rationale
An increase in respiratory rate is not necessarily an indication that CPT has been effective for a client with COPD. In fact, an increased respiratory rate could indicate respiratory distress, which could suggest that the therapy has not been effective or that the client’s condition has worsened.

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Naxlex Comprehensive Predictor Exams

A patient with diabetic peripheral neuropathy has been taking pregabalin for the past four days. Which finding would indicate to the nurse that the medication is effective?

Correct Answer is A

Explanation

A client with chronic obstructive pulmonary disease (COPD) receives a prescription for chest physiotherapy (CPT) to help mobilize secretions. Following the therapy, which finding indicates to the nurse that the intervention was effective?

Correct Answer is B

Explanation

A male adult is admitted due to an overdose of acetaminophen. After being transferred to the mental health unit, the patient is informed that he has liver damage. What is the most crucial information for the nurse to include in the patient’s discharge plan?

The patient provides three positive responses to items on the CAGE (Cut down, Annoyed, Guilty, Eye-opener) query. What interpretation should the nurse provide to the patient?

The nurse is reviewing laboratory results for a patient scheduled for a cholecystectomy. Which result is most important for the nurse to report to the surgeon?

An adult patient visits the clinic expressing concern about a lump that appeared on their neck about a week ago. Upon examination, the nurse finds a large, non-tender, hardened left subclavian lymph node without any overlying tissue inflammation. What could these findings indicate?

While conducting an admission assessment of a female client with bipolar disorder, the client suddenly starts to undress and throw her clothes around the room. What should be the nurse’s initial action?