The primary caregiver of an older adult client calls the nurse at the outpatient clinic due to a sudden onset of changes in the client's behavior. The caregiver reports to the nurse that the client normally is oriented and able to answer questions but now is confused and agitated. What
action(s) should the nurse take? Select all that apply.

Ask if the client is experiencing any pain with urination.

Determine if the client has recently experienced a fall.

Provide instruction on taking the client's temperature.

Encourage increased intake of high protein foods.

Review the client's current food and medication allergies

Answer and Explanation

Correct Answer : A,B,C,E

A.   Ask if the client is experiencing any pain with urination. Urinary tract infections (UTIs) are common in older adults and can lead to sudden changes in behavior, including confusion and agitation.
B.   Determine if the client has recently experienced a fall. Falls can lead to head injuries or other trauma that may cause confusion or changes in behavior in older adults.
C.   Provide instruction on taking the client's temperature. Fever can be a sign of infection, which might be causing the sudden behavioral changes. Monitoring temperature can help identify if an infection is present.
D.   Encourage increased intake of high protein foods. While good nutrition is important, it is not directly related to the sudden onset of confusion and agitation, making this a less immediate priority.
E.   Review the client's current food and medication allergies. Allergic reactions to foods or
medications can cause sudden behavioral changes. Reviewing allergies can help determine if this is the cause of the symptoms.

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Correct Answer is B

Explanation

A. An increase in breath sounds may suggest improved airflow, but it does not necessarily indicate effective mobilization of secretions.
B. Absence of fine crackles indicates that there are no longer small airway secretions or fluid in the lungs, suggesting that the chest physiotherapy was effective in mobilizing secretions.
C. While the absence of coarse crackles is also a positive finding, fine crackles specifically indicate fluid or secretions in the small airways, making their absence a more direct indicator of the effectiveness of chest physiotherapy.

D. An increase in respiratory rate may indicate respiratory distress or worsening of the condition, rather than effectiveness of the chest physiotherapy in mobilizing secretions.

A. Compare muscle strength bilaterally. B. Determine apical pulse rate and rhythm. C. Assess strength of deep tendon reflexes. D. Observe color and amount of urine.

Correct Answer is B

Explanation

A. Compare muscle strength bilaterally. While hyperkalemia can lead to muscle weakness, assessing muscle strength bilaterally is not the most critical intervention in this scenario. The priority is to assess for cardiac manifestations of hyperkalemia.
B. Determine apical pulse rate and rhythm. Hyperkalemia can cause life-threatening cardiac dysrhythmias, including bradycardia, heart block, and ventricular tachycardia. Assessing the apical pulse rate and rhythm can provide essential information about cardiac function and help identify potential dysrhythmias.
C. Assess strength of deep tendon reflexes. Hyperkalemia can affect neuromuscular function, leading to hyperreflexia or diminished reflexes. While assessing deep tendon reflexes is
important, it is not as critical as assessing cardiac function in a client with known hyperkalemia.
D. Observe color and amount of urine. While changes in urinary output and characteristics may indicate renal impairment associated with hyperkalemia, the priority in this situation is to assess for cardiac manifestations of hyperkalemia.

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

After receiving report, the nurse can most safely plan to assess which client last?

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