The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.

Determine if the client has recently experienced a fall.

Instruct the adult child to check the client's temperature.

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.

Answer and Explanation

Correct Answer : A,B,C,E

A.   Falls can lead to head injuries or subdural hematomas, which can cause confusion in older adults. It is important to assess for recent trauma as a possible cause of the confusion.
B.   An elevated temperature can indicate an infection, such as a urinary tract infection (UTI) or pneumonia, which are common causes of acute confusion in older adults.
C.   Pain with urination is a symptom of a UTI, which can lead to confusion, especially in elderly patients with Parkinson's disease.
D.   While maintaining adequate nutrition is important, increasing protein intake does not directly address the sudden onset of confusion.
E.   New medications or allergic reactions can lead to confusion. A medication interaction or an allergic reaction to a new food could be a contributing factor.

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Correct Answer is D

Explanation

A. Identifying triggers may be beneficial, but the client is currently in a state of severe anxiety, and immediate intervention to address the symptoms is needed.
B. Exploring past behaviors can be addressed later; the immediate focus should be on managing the acute symptoms of anxiety.

C. Attempting to distract the client can be helpful, but providing reassurance and addressing safety concerns take precedence.
D. Speaking calmly to the client and providing assurance of safety is an appropriate first step in managing severe anxiety. Once the client is more settled, other interventions can be explored.

A. A resting respiratory rate of 35 breaths/minute. B. Flaring of the nares. C. Diaphragmatic respirations. D. Bilateral bronchial breath sounds.

Correct Answer is B

Explanation

A. A respiratory rate of 35 breaths/minute can be normal for a 2-year-old, so it is not necessarily indicative of distress by itself.

B.Flaring of the nares is a sign of increased work of breathing and is an indication of respiratory distress, as the child is using accessory muscles to breathe.

C.Diaphragmatic respirations are typical for young children and not indicative of distress unless other signs are present.

D.Bilateral bronchial breath sounds do not necessarily indicate respiratory distress and could be normal depending on the context.

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The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

Correct Answer is D

Explanation

A 2-year-old is brought to the emergency department (ED) with a history of several days of rhinitis and now exhibits a productive barking cough and difficulty breathing. Which additional finding should alert the nurse that the child is experiencing respiratory distress?

Correct Answer is B

Explanation

Exhibits Nursing actions: Indicated/contraindicated/non-urgent

The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care?

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching an 18-gauge needle. Which action should the charge nurse take?

The practical nurse (PN) believes that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Which action should the PN take?

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Exhibits What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.