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. Measure urinary output every hour. Dopamine is commonly used to improve blood pressure and renal perfusion in hypotensive clients. Monitoring urinary output is crucial because dopamine can increase renal blood flow and urine output. Hourly measurement allows for early detection of changes in renal function and urine output, enabling prompt intervention if needed.
B. Initiate seizure precautions. Seizures are not a common adverse effect of dopamine administration. Therefore, initiating seizure precautions is unnecessary in this context.
C. Assess pupillary response to light hourly. While assessing pupillary response is important in neurological assessments, it is not a priority intervention specifically related to dopamine
administration for hypotension.

D. Monitor serum potassium frequently. Dopamine administration is not directly associated with alterations in serum potassium levels. While electrolyte monitoring is important in some
situations, it is not the primary concern when administering dopamine for hypotension. Monitoring urinary output is more pertinent in this scenario.

Correct Answer is []

Explanation

- Potential Condition:

Stage 2 pressure injury

- Actions to Take:

C. Clean the area and dry carefully: Proper wound care involves cleaning the area to prevent infection and promote healing. Cleaning the erythematous area on the left heel and ensuring
it is dry can help prevent further skin breakdown and promote healing.

B. Hold the hydrochlorothiazide: Hydrochlorothiazide is a diuretic that can increase urine output and potentially lead to dehydration, which may exacerbate the client's condition. Holding the medication temporarily can help prevent further fluid loss and dehydration, which is crucial for wound healing.

- Parameters to Monitor:

B. Skin color: Monitoring the skin color around the erythematous area on the left heel can help assess tissue perfusion and identify any signs of deterioration or improvement in the wound condition.
D. Fluid balance: Monitoring the client's fluid balance, including intake and output, is essential for assessing hydration status and ensuring adequate tissue perfusion, which is vital for wound healing and overall patient well-being.

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Naxlex Comprehensive Predictor Exams

A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Correct Answer is A

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

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