The daughter of an older woman who has Parkinson's disease, calls the clinic and reports that her mother has been confused for the past week. Which action(s) should the nurse take? (Select all that apply.)

Determine if the mother has recently experienced a fall.

Review the client's current food and medication allergies.

Encourage increased intake of high protein foods.

Instruct the daughter to check her mother's temperature.

Ask if the mother is experiencing any pain with urination.

Answer and Explanation

Correct Answer : A,D,E

Choice A reason: This is a correct answer because determining if the mother has recently experienced a fall is important to rule out any head injury or concussion that could cause confusion. Parkinson's disease can increase the risk of falls due to impaired balance, coordination, and mobility.

Choice B reason: This is not a correct answer because reviewing the client's current food and medication allergies is not relevant to the mother's confusion. However, it may be important to review the client's current medications and dosages to check for any adverse effects or interactions that could affect cognition.

Choice C reason: This is not a correct answer because encouraging increased intake of high protein foods is not helpful for the mother's confusion. In fact, high protein foods may interfere with the absorption of levodopa, a medication used to treat Parkinson's disease symptoms. The nurse should advise the daughter to consult with a dietitian about the optimal timing and amount of protein intake for her mother.

Choice D reason: This is a correct answer because instructing the daughter to check her mother's temperature is important to detect any fever or infection that could cause confusion. Older adults are more susceptible to infections such as urinary tract infections (UTIs), pneumonia, or sepsis, whih can affect mental status.

Choice E reason: This is a correct answer because asking if the mother is experiencing any pain with urination is important to screen for any UTI that could cause confusion. UTIs are common in older adults due to reduced bladder function, incomplete emptying, and decreased immunity. UTIs can cause symptoms such as dysuria, frequency, urgency, hematuria, and delirium.

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Correct Answer is C

Explanation

Choice A reason: Reinforcing need for adequate hydration is not the most important action for the nurse to implement, as this is a general recommendation for all clients and does not address the specific needs of this client. This is a distractor choice.

Choice B reason: Providing typed instructions for healthy diet selection is not the most important action for the nurse to implement, as this may not be feasible or accessible for this client who lives in a poor neighborhood and may have limited resources and literacy. This is another distractor choice.

Choice C reason: Scheduling follow-up appointments with specialists is the most important action for the nurse to implement, as this can ensure that this client receives continuous and comprehensive care for their complex and chronic conditions, which can improve their outcomes and quality of life. Therefore, this is the correct choice.

Choice D reason: Demonstrating specific breathing and walking exercises is not the most important action for the nurse to implement, as this can be done by other health care professionals or at home by the client. This is another distractor choice.

A. Serum potassium, calcium, and phosphorus B. Erythrocytes, hemoglobin, and hematocrit C. Leukocytes, neutrophils, and thyroxine D. Blood pressure, heart rate, and temperature

Correct Answer is A

Explanation

Choice A reason: This is the correct answer because serum potassium, calcium, and phosphorus are laboratory results that should be closely monitored in a client who has end-stage renal disease (ESRD). ESRD is a chronic condition that causes irreversible loss of kidney function and accumulation of waste products and fluids in the body. Potassium is an electrolyte that regulates nerve and muscle function and cardiac rhythm. ESRD can cause hyperkalemia (high potassium levels) due to reduced excretion by the kidneys. Hyperkalemia can cause cardiac arrhythmias, muscle weakness, or paralysis. Calcium and phosphorus are minerals that maintain bone health and acid-base balance. ESRD can cause hypocalcemia (low calcium levels) due to impaired vitamin D metabolism and hyperphosphatemia (high phosphorus levels) due to reduced excretion by the kidneys. Hypocalcemia can cause muscle cramps, tetany, or seizures. Hyperphosphatemia can cause soft tissue calcification, bone pain, or fractures.

Choice B reason: Erythrocytes, hemoglobin, and hematocrit are laboratory results that are not as critical as serum potassium, calcium, and phosphorus in a client who has end-stage renal disease (ESRD). Erythrocytes are red blood cells that carry oxygen from the lungs to the tissues. Hemoglobin is a protein in erythrocytes that binds oxygen. Hematocrit is the percentage of blood volume that is occupied by erythrocytes. ESRD can cause anemia (low erythrocyte, hemoglobin, and hematocrit levels) due to reduced production of erythropoietin, a hormone that stimulates erythrocyte formation, by the kidneys. Anemia can cause fatigue, pallor, or shortness of breath.

Choice C reason: Leukocytes, neutrophils, and thyroxine are laboratory results that are not as relevant as serum potassium, calcium, and phosphorus in a client who has end-stage renal disease (ESRD). Leukocytes are white blood cells that fight infection and inflammation. Neutrophils are a type of leukocyte that respond to bacterial infection. Thyroxine is a hormone that regulates metabolism and growth. ESRD can cause leukopenia (low leukocyte levels) and neutropenia (low neutrophil levels) due to impaired immune function and increased susceptibility to infection. ESRD can also cause hypothyroidism (low thyroxine levels) due to reduced clearance of thyroid hormones by the kidneys. Hypothyroidism can cause weight gain, cold intolerance, or depression.

Choice D reason: Blood pressure, heart rate, and temperature are not laboratory results, but vital signs that should be monitored in a client who has end-stage renal disease (ESRD). Blood pressure is the force of blood against the walls of the arteries. Heart rate is the number of times the heart beats per minute. Temperature is the measure of body heat. ESRD can cause hypertension (high blood pressure) due to fluid overload and activation of the renin-angiotensin-aldosterone system, a hormonal pathway that regulates blood pressure and fluid balance. Hypertension can cause headache, chest pain, or stroke. ESRD can also cause tachycardia (high heart rate) due to anemia, fluid overload, or electrolyte imbalance. Tachycardia can cause palpitations, dizziness, or heart failure. ESRD can also cause fever (high temperature) due to infection or inflammation. Fever can cause chills, sweating, or delirium.

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The daughter of an older woman who has Parkinson's disease, calls the clinic and reports that her mother has been confused for the past week. Which action(s) should the nurse take? (Select all that apply.)

Nursing Test Bank

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