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 A

Explanation

A. Avoid stimulation of the breasts and wear a tight bra: This is the most appropriate recommendation for a bottle-feeding postpartum client with breast engorgement. Minimizing breast stimulation and wearing a supportive, tight-fitting bra can help reduce milk production and alleviate discomfort.

B. Express a small amount of breast milk by hand: This action may provide temporary relief but can stimulate further milk production, which is not advisable for a client who is bottle-feeding and attempting to suppress lactation.

C. Place warm packs on both breasts: Warmth can promote milk flow and is typically recommended for breastfeeding mothers. For a bottle-feeding client, cold compresses are more appropriate to reduce engorgement.

D. Take a prescribed analgesic and expose breasts to air: While analgesics can help manage discomfort, exposing the breasts to air has no therapeutic benefit for engorgement and may increase discomfort. This is not the best overall recommendation.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"D"}

Explanation

Short-term memory loss: While some degree of memory loss can be a normal part of aging, significant short-term memory loss in the context of elder mistreatment can indicate neglect or psychological abuse. It might reflect isolation or a lack of proper mental stimulation and care.
Pressure injuries: These are clear indicators of neglect. Pressure injuries, such as bedsores, occur when a person is not moved or repositioned regularly. They can suggest that the caregiver is not providing adequate care or attention to the client's physical needs.
Malnutrition: This is a strong sign of neglect. Malnutrition, evidenced by loss of subcutaneous fat and low body weight, indicates that the client is not receiving adequate nutrition. This could be due to neglect in providing food or a lack of attention to dietary needs, which is a form of mistreatment.

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Naxlex Comprehensive Predictor Exams

A postpartum client who is bottle-feeding develops breast engorgement. Which is the best recommendation for the nurse to provide this client?

Correct Answer is A

Explanation

Exhibits The nurse reviews the findings in the history and physical. Select from Word Choices to complete the sentence. The nurse recognizes that dropdown ,dropdown and dropdown are findings consistent with elder mistreatment.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"D"}

Explanation

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