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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Free Nursing Study Resources

Correct Answer is C,A,B,D

Explanation

Choice C rationale

The first step in managing a patient with abdominal pain and distention is to complete a focused assessment. This will help the nurse determine the severity of the patient’s condition and guide subsequent interventions.

Choice A rationale

Elevating the head of the bed can help reduce the risk of aspiration, especially in a patient who has recently vomited. This is particularly important in this case as the patient’s vomit is dark brown, indicating possible upper gastrointestinal bleeding.

Choice B rationale

Sending the emesis sample to the lab is important for determining the cause of the patient’s symptoms. The lab can analyze the sample for the presence of blood or other abnormalities.

Choice D rationale

Offering PRN pain medication is important for patient comfort. However, it should be done after the assessment and initial interventions have been completed. The medication may mask symptoms that could provide important diagnostic information.

A. The patient’s currently prescribed medications. B. The increasing confusion of the patient. C. The patient’s healthcare power of attorney. D. The fall from a ladder as the reason for admission.

Correct Answer is D

Explanation

Choice A rationale
While it’s important to know the patient’s current medications as they can influence the patient’s condition and treatment plan, this information is not the most critical to convey first in this situation.
Choice B rationale
The increasing confusion of the patient is a significant symptom, especially after a fall. It could indicate a possible head injury. However, the cause of the confusion (the fall) should be communicated first.
Choice C rationale
Knowing who holds the patient’s healthcare power of attorney is important, especially if the patient’s condition worsens and decisions need to be made on their behalf. However, this information is not the most critical to convey first.
Choice D rationale
The fall from a ladder as the reason for admission is the most important information to provide first. This gives the healthcare provider immediate context about the potential severity and type of injuries, guiding further assessment and treatment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C,A,B,D

Explanation

Correct Answer is D

Explanation

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