The nurse is caring for an older adult client who has an infection and a fever of 38°C (100.4°F).

The nurse should monitor the client for which of the following complications?

Dehydration

Hypothermia

Seizures

Delirium

Answer and Explanation

The Correct Answer is D

The correct answer is D.

Delirium.

The nurse should monitor the client for delirium, which is a state of acute mental confusion that can be caused by fever, infection, dehydration, or medications.

Delirium can affect the client’s cognition, attention, orientation, memory, and behavior. It can also increase the risk of falls, complications, and mortality.

Choice A is wrong because dehydration is not a complication of fever, but rather a possible cause of fever.

Dehydration occurs when the body loses more fluid than it takes in, and it can impair the body’s ability to regulate its temperature. Dehydration is more common and dangerous in older adults because they have a lower volume of water in their bodies, a weaker thirst response, and may have conditions or medications that increase fluid loss.

Choice B is wrong because hypothermia is not a complication of fever, but rather a condition of abnormally low body temperature.

Hypothermia can occur when the body loses heat faster than it can produce it, such as in cold weather or water exposure. Hypothermia can affect the brain, heart, and other organs, and can lead to death if not treated promptly.

Choice C is wrong because seizures are not a common complication of fever in older adults.

Seizures are sudden episodes of abnormal electrical activity in the brain that can cause changes in movement, sensation, behavior, or consciousness.

Seizures can have various causes, such as head injury, stroke, infection, or epilepsy.

Fever-induced seizures are more likely to occur in young children than in older adults.

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Correct Answer is C

Explanation

The correct answer is C.

Check for bladder distention or fecal impaction.

Autonomic dysreflexia is a disorder of autonomic nervous system dysregulation that occurs in patients with a spinal cord injury above T6.

It is caused by an exaggerated reflex response of the sympathetic nervous system due to an irritating stimulus below the spinal cord injury.It leads to severe hypertension and is a medical emergency.

Bladder or bowel distension are the most common triggers of autonomic dysreflexia.

Therefore, the priority nursing intervention is to check for bladder distention or fecal impaction and relieve them as soon as possible.

This can help to eliminate the stimulus and lower the blood pressure.

Choice A is wrong because administering antihypertensive medication as prescribed may not be effective or appropriate for autonomic dysreflexia.

The hypertension is caused by a reflex mechanism and not by a primary cardiovascular disorder.Moreover, antihypertensive drugs may cause hypotension once the stimulus is removed.

Choice B is wrong because elevating the head of bed to 90 degrees may not be enough to lower the blood pressure.It may also increase the risk of orthostatic hypotension once the stimulus is removed.However, sitting the patient upright and loosening any tight clothing are recommended as initial steps to reduce the blood pressure.

Choice D is wrong because applying a cooling blanket to lower body temperature is not indicated for autonomic dysreflexia.There is no evidence that body temperature is elevated or contributes to the hypertension in this condition.A cooling blanket may also cause vasoconstriction and worsen the hypertension.

Normal ranges for blood pressure vary depending on age, sex, and other factors.

However, a general guideline is that systolic blood pressure should be less than 120 mm Hg and diastolic blood pressure should be less than 80 mm Hg for most adults.

Normal ranges for heart rate also vary depending on age, activity level, and other factors.

However, a general guideline is that resting heart rate should be between 60 and 100 beats per minute for most adults.

References:.

A. Physical activity and exercise can increase your levels of serotonin and endorphins, which are natural mood boosters. B. Physical activity and exercise can improve your cardiovascular health, muscle strength, balance and flexibility. C. Physical activity and exercise can reduce your stress, anxiety, pain and inflammation. D. Physical activity and exercise can enhance your self-esteem, confidence and sense of accomplishment. E. Physical activity and exercise can help you sleep better at night and feel more refreshed in the morning.

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

Explanation

The correct answer isA, B, C, D and E.

All of these statements are true and should be included in the nurse’s education.

Physical activity and exercise have many benefits for older adults with depression, such as:.

• Increasing the levels ofserotonin and endorphins, which are natural mood boosters that can help reduce depression symptoms.

• Improvingcardiovascular health, muscle strength, balance and flexibility, which can prevent or delay chronic diseases, reduce the risk of falls and injuries, and enhance functional ability.

• Reducingstress, anxiety, pain and inflammation, which can worsen depression and affect physical health.

• Enhancingself-esteem, confidence and sense of accomplishment, which can improve self-image, social interaction and coping skills.

• Helping tosleep better at night and feel more refreshed in the morning, which can improve mood, energy and cognitive function.

Choice A is correct because physical activity and exercise can increase the levels of serotonin and endorphins, which are natural mood boosters that can help reduce depression symptoms.

Choice B is correct because physical activity and exercise can improve cardiovascular health, muscle strength, balance and flexibility, which can prevent or delay chronic diseases, reduce the risk of falls and injuries, and enhance functional ability.

Choice C is correct because physical activity and exercise can reduce stress, anxiety, pain and inflammation.

A. Physical activity and exercise can increase your levels of serotonin and endorphins, which are natural mood boosters B.

Physical activity and exercise can improve your cardiovascular health, muscle strength, balance and flexibility C.

Physical activity and exercise can reduce your stress, anxiety, pain and inflammation D.

Physical activity and exercise can enhance your self-esteem, confidence and sense of accomplishment E.

Physical activity and exercise can help you sleep better at night and feel more refreshed in the morning

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The nurse is caring for an older adult client who has an infection and a fever of 38°C (100.4°F). The nurse should monitor the client for which of the following complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who has had a spinal cord injury at level C5-C6 as a result of an automobile accident. The patient suddenly develops severe hypertension, throbbing headache, blurred vision, and bradycardia. What is the priority nursing intervention?

Correct Answer is C

Explanation

A nurse is educating an older adult client who has depression about the benefits of physical activity and exercise. Which of the following statements should the nurse include? (Select all that apply.).

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

Explanation

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The nurse is caring for an older adult client who has an infection and a fever of 38°C (100.4°F).

The nurse should monitor the client for which of the following complications?