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 C

Explanation

A. Phobia.
A phobia is an irrational fear of a specific object, situation, or activity that leads to a desire to avoid it. The client's behavior is more characteristic of a compulsion rather than a phobia.

B. Obsession.
An obsession is an intrusive, unwanted thought, image, or urge that causes significant anxiety.
While the client's fear of contamination could be an obsession, the handwashing itself is a compulsion.

C. Compulsion.
This is the correct answer because a compulsion is a repetitive behavior or mental act that a person feels driven to perform in response to an obsession. The client's excessive handwashing ritual is a classic example of a compulsion.

D. Addiction.
Addiction involves a compulsive need for and use of a habit-forming substance or behavior, typically involving a sense of euphoria or pleasure, which is not applicable to the client's behavior.

A. Blood glucose of 90 mg/dl. (5 mmol/L). B. Potassium level of 4 mEq/L (4 mmol/L) C. Hemoglobin level of 13 g/dL (130 g/L). D. Serum creatinine of 5 mg/dL (442 pmol/L).

Correct Answer is D

Explanation

A. A blood glucose level of 90 mg/dL is within the normal reference range of 74 to 106 mg/dL, so it is not a concern.
B. A potassium level of 4 mEq/L is also within the normal reference range of 3.5 to 5.0 mEq/L, so it does not need to be reported.
C. Although the hemoglobin level of 13 g/dL is below the reference range provided, it is not critically low and may not be urgent unless the patient has symptoms of anemia or other related issues.
D. A serum creatinine level of 5 mg/dL is significantly higher than the normal reference range of 0.5 to 1.1 mg/dL. This indicates renal impairment, which could affect the patient's ability to clear medications used during surgery and could lead to postoperative complications. Therefore, it is crucial to report this finding to the surgeon immediately.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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