The nurse is caring for an older adult client that is exhibiting signs of confusion. Which intervention should the nurse implement?

Offer water to the client hourly.

Review the intake and output record.

Reduce dairy product intake.

Increase daily sodium intake.

Answer and Explanation

The Correct Answer is B

Choice B reason:

Reviewing the intake and output record is essential for identifying potential causes of the client’s confusion, such as dehydration or electrolyte imbalances. Monitoring fluid intake and output helps assess the client’s hydration status and detect any imbalances that could contribute to confusion. This intervention allows the nurse to make informed decisions about fluid and electrolyte management to address the underlying cause of the confusion.

Choice A reason:

Offering water to the client hourly can help maintain hydration but may not be sufficient if the client has an underlying condition affecting fluid balance. It is important to first assess the client’s overall fluid status through intake and output records before implementing hydration strategies.

Choice C reason:

Reducing dairy product intake is not directly related to addressing confusion. Unless the client has a specific intolerance or allergy to dairy, this intervention is unlikely to impact their cognitive status.

Choice D reason:

Increasing daily sodium intake can be harmful if the client does not have a sodium deficiency. Excess sodium can lead to fluid retention and exacerbate confusion, especially in older adults. It is important to assess the client’s electrolyte levels before making any changes to sodium intake.

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Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason:

Beans are an excellent source of non-heme iron, which is important for clients with iron-deficiency anemia. They also provide protein and fiber, making them a nutritious addition to the diet.

Choice C reason:

Raisins are a good source of iron and can help increase iron levels in the body. They are also a convenient snack that can be easily incorporated into the diet.

Choice D reason:

Oranges are rich in vitamin C, which enhances the absorption of non-heme iron from plant-based sources. Including vitamin C-rich foods like oranges in the diet helps improve iron absorption and supports overall health.

Choice E reason:

Spinach is high in non-heme iron and provides essential vitamins and minerals. It is a versatile vegetable that can be added to various dishes to boost iron intake.

Choice B reason:

Cucumber is low in iron and does not significantly contribute to increasing iron levels. While it is a healthy vegetable, it is not particularly beneficial for addressing iron-deficiency anemia.

A. Call the healthcare provider to clarify if the client may have ice cream as requested. B. Offer to prepare a chocolate-flavored liquid nutritional supplement poured over ice. C. Provide the chocolate ice cream after determining the presence of bowel sounds. D. Explain that a popsicle or a cup of gelatin can be provided rather than ice cream.

Correct Answer is D

Explanation

Choice D reason:

Explaining that a popsicle or a cup of gelatin can be provided rather than ice cream is appropriate because these options are clear liquids, which are allowed on a clear liquid diet. Clear liquids are easily digestible and leave no residue in the digestive tract, making them suitable for pre-surgical preparation. This ensures that the client adheres to the dietary restrictions necessary for surgery.

Choice A reason:

Calling the healthcare provider to clarify if the client may have ice cream is unnecessary because ice cream is not considered a clear liquid and does not meet the requirements of a clear liquid diet. The nurse should provide alternatives that fit within the prescribed diet.

Choice B reason:

Offering a chocolate-flavored liquid nutritional supplement poured over ice is not appropriate because it may not be considered a clear liquid. The focus should be on providing options that are clearly within the guidelines of a clear liquid diet.

Choice C reason:

Providing chocolate ice cream after determining the presence of bowel sounds is not suitable because ice cream is not a clear liquid. The nurse should adhere to the clear liquid diet prescribed for the client to ensure proper preparation for surgery.

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The nurse is caring for an older adult client that is exhibiting signs of confusion. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When conducting diet teaching for a client who has iron-deficiency anemia, which foods should the nurse encourage the client to eat? (Select all that apply.)

Correct Answer is ["A","C","D","E"]

Explanation

A clear liquid breakfast is prescribed for a client who is scheduled for surgery later today. The client asks the nurse for a small cup of chocolate ice cream. Which action should the nurse take?

Correct Answer is D

Explanation

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