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A nurse is reviewing the medical record of an older adult client who is confused to place and time. Which of the following actions should the nurse plan to take?

Exhibits

Place the client on a low-protein diet

Restrict the client's intake of dietary sodium.

Ask the provider to decrease the magnesium hydroxide dosage.

Request a prescription to discontinue diphenhydramine.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Placing the client on a low-protein diet is not appropriate based solely on the provided information.

Choice B rationale:

Restricting dietary sodium might be considered for specific conditions but is not directly related to the client's confusion.

Choice C rationale:

A high magnesium level can contribute to confusion in older adults. Requesting a reduction in the magnesium hydroxide dosage can help address this issue.

Choice D rationale:

Discontinuing diphenhydramine might be considered if it is contributing to the client's confusion, but there is no specific information provided to support this action.

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Correct Answer is A

Explanation

Choice A rationale:

Absent deep tendon reflexes can be a sign of magnesium toxicity, which is a potential adverse effect of magnesium sulfate infusion.

Choice B rationale:

A fetal heart rate of 120/min is within a normal range and is not concerning.

Choice C rationale:

Blood pressure of 150/92 mm Hg is elevated but is expected in a client with preeclampsia.

Choice D rationale:

Facial flushing can be a common side effect of magnesium sulfate and is not a priority finding to report.

A. A client who developed influenza after receiving the vaccine last year B. A client who has hypertension C. A client who has a history of Guillain-Barré syndrome D. A client who has an allergy to dairy products.

Correct Answer is C

Explanation

Choice A rationale:

Developing influenza after receiving the vaccine the previous year is not a contraindication for receiving the vaccine this year. In fact, the vaccine is recommended annually.

Choice B rationale:

Hypertension is not a contraindication for receiving the influenza vaccine.

Choice C rationale:

Clients with a history of Guillain-Barré syndrome should generally avoid receiving the influenza vaccine due to a potential increased risk of recurrence of the syndrome.

Choice D rationale:

Allergies to dairy products are not a contraindication for receiving the influenza vaccine.

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A nurse is reviewing the medical record of an older adult client who is confused to place and time. Which of the following actions should the nurse plan to take? Exhibits

Nursing Test Bank

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A nurse is reviewing the medical record of an older adult client who is confused to place and time. Which of the following actions should the nurse plan to take?

Exhibits