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 D

Explanation

A. Removing dentures or other oral appliances is not directly related to managing obstructive sleep apnea. While it may be necessary for certain procedures or assessments, it does not address the client's OSA during narcotic administration.

B. Elevating the head of the bed to a 45-degree angle is a standard practice to prevent aspiration during narcotic administration, but it does not specifically address the client's obstructive sleep apnea.

C. Lifting and locking the side rails in place is important for client safety but does not directly address the client's obstructive sleep apnea.

D. Applying the client's positive airway pressure (PAP) device is crucial for managing obstructive sleep apnea, especially when administering a narcotic analgesic, which can further depress respiratory function. The PAP device helps maintain airway patency and prevent apneic episodes, reducing the risk of respiratory complications in clients with OSA.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Semi Fowler's position:

- This position involves raising the head of the bed to an angle of 30 to 45 degrees. It is

commonly used to improve respiratory function and comfort in patients who are experiencing

difficulty breathing. By elevating the head and torso, this position facilitates better lung expansion, helping to improve oxygenation.

Promote lung expansion:

- In patients with respiratory issues such as pneumonia, positioning that enhances lung expansion is critical. Semi Fowler's position helps to reduce pressure on the diaphragm, allowing for more effective lung expansion and improved oxygenation. This is particularly important for a patient with decreased breath sounds and consolidation in the lungs, as it aids in alleviating respiratory distress and improving gas exchange.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer a narcotic analgesic to a client with a fractured femur who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement?

Correct Answer is D

Explanation

Exhibits The nurse should place the client in a position to promote

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Which laboratory test results should the nurse monitor in a client who has end-stage renal disease (ESRD)?

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