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 B

Explanation

A. The UAP should not make medication decisions; only a nurse or healthcare provider should do this after assessment.
B. The nurse should evaluate the client’s heart rhythm to determine the effectiveness of the amiodarone and to assess for any arrhythmias or side effects of the medication.
C. Checking the regularity of peripheral pulses is important but secondary to assessing the heart rhythm directly.
D. Restarting the IV infusion might be necessary if there are issues with the IV site, but the primary concern is the client's cardiac status.

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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

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

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). What nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

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 with an acute myocardial infarction (MI) is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response?

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take?