A 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.
What action(s) should the nurse take? Select all that apply.
Ask if the client is experiencing any pain with urination.
Encourage increased intake of high protein foods.
Review the client’s current food and medication allergies.
Determine if the client has recently experienced a fall.
Provide instruction on taking the client’s temperature.
Correct Answer : A,D,E
Choice A rationale
Sudden onset of confusion in an older adult could be a sign of a urinary tract infection (UTI). UTIs can cause delirium and behavioral changes in older adults. Therefore, asking if the client is experiencing any pain with urination could help identify a potential UTI.
Choice B rationale
While high protein foods are generally beneficial for health, there is no direct link between increased intake of high protein foods and sudden onset of confusion. Therefore, this option is not the most appropriate action in this situation.
Choice C rationale
Reviewing the client’s current food and medication allergies is always important in healthcare settings. However, it may not directly address the sudden onset of confusion unless the client has had a recent change in diet or medication that could have triggered an allergic reaction leading to confusion.
Choice D rationale
A recent fall could potentially cause a sudden change in mental status due to a head injury or other trauma. Therefore, determining if the client has recently experienced a fall is an appropriate action.
Choice E rationale
Fever can cause confusion, especially in older adults. Therefore, providing instruction on taking the client’s temperature can help the caregiver monitor for signs of infection that could be contributing to the client’s confusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Urinating only once or twice a day is not a typical symptom of type I diabetes mellitus. In fact, frequent urination is a common symptom of diabetes.
Choice B rationale
Rapid weight gain is not typically associated with type I diabetes mellitus. On the contrary, unexplained weight loss is a common symptom.
Choice C rationale
Refusing to eat favorite meals is not a typical symptom of type I diabetes mellitus. Changes in appetite can occur in various conditions, but they are not specific to diabetes.
Choice D rationale
Drinking more fluids than usual, also known as polydipsia, is a common symptom of type I diabetes mellitus. This is often accompanied by polyuria (frequent urination) due to high blood sugar levels.
Correct Answer is A
Explanation
Choice A rationale
Testing the fluid on the dressing for glucose is the immediate action the nurse should take. Clear fluid could be cerebrospinal fluid (CSF), which is often released following spinal surgery. CSF contains glucose, so a positive glucose test would confirm it is CSF.
Choice B rationale
Replacing the dressing using a compression bandage is not the immediate action the nurse should take. While it is important to manage the drainage and prevent infection, the nurse first needs to identify what the clear fluid is.
Choice C rationale
Marking the drainage area with a pen and continuing to monitor is not the immediate action the nurse should take. While this can be part of ongoing wound care and monitoring, the nurse first needs to identify what the clear fluid is.
Choice D rationale
Documenting the findings in the electronic medical record is an important step, but it should not be the immediate action. The nurse first needs to identify what the clear fluid is, as it could indicate a complication from the surgery.
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