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 ["A","B","C","E"]

Explanation

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

The nurse should ask the client about medications, vision problems, home environment, and urinary incontinence as these are all factors that could contribute to falls in older adults.

• Medicationscan increase the risk of falls because they can cause side effects such as drowsiness, dizziness, confusion, or low blood pressure.Some medications that can increase the risk of falls include sedatives, antidepressants, antihypertensives, diuretics, and anticholinergics.

• Vision problemscan impair the ability to see obstacles, judge depth and distance, or adjust to changes in light.Some vision problems that can increase the risk of falls include cataracts, glaucoma, macular degeneration, and diabetic retinopathy.

• Home environmentcan pose safety hazards that can cause tripping, slipping, or losing balance.Some home hazards that can increase the risk of falls include loose rugs, clutter, poor lighting, slippery floors, uneven surfaces, and lack of handrails or grab bars.

• Urinary incontinencecan lead to rushed movements to the bathroom or frequent nighttime trips that can increase the risk of falls.Urinary incontinence can be caused by various factors such as bladder infections, prostate problems, pelvic floor weakness, or medication side effects.

Choice D is wrong because thyroid function is not a direct factor that contributes to falls in older adults.However, thyroid disorders such as hyperthyroidism or hypothyroidism can affect other factors such as muscle strength, bone density, heart rate, or blood pressure that can indirectly increase the risk of falls.

Normal ranges for thyroid function tests vary depending on the laboratory and the method used.However, a common reference range for thyroid-stimulating hormone (TSH) is 0.4 to 4.0 mIU/L and for free thyroxine (FT4) is 0.8 to 1.8 ng/dL.

A. Follow up with the primary care provider regularly. B. Avoid alcohol and tobacco use C. Take over-the-counter sleeping pills as needed. D. Engage in physical and mental activities daily. E. Wear glasses and hearing aids if prescribed.

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

Explanation

The correct answer isA, B and D.

Here is why:.

• Following up with the primary care provider regularly can help detect and treat any medical conditions that may cause or contribute to delirium, such as infections, electrolyte imbalances, or medication side effects.

• Avoiding alcohol and tobacco use can prevent delirium caused by intoxication or withdrawal, as well as improve overall health and cognitive function.

• Engaging in physical and mental activities daily can help maintain brain health, prevent cognitive decline, and reduce stress and boredom that may trigger delirium.

Choice C is wrong because taking over-the-counter sleeping pills as needed can increase the risk of delirium, especially in older adults.Sleeping pills can cause confusion, drowsiness, memory impairment, and falls that may lead to delirium.Instead of sleeping pills, it is better to have good sleep habits such as uninterrupted sleep, avoiding caffeine and naps, and having a regular bedtime routine.

Choice E is wrong because wearing glasses and hearing aids if prescribed can help prevent delirium, not cause it.Sensory impairment such as poor vision and hearing can make a person more prone to delirium, as they may feel disoriented, isolated, or misunderstood.Wearing glasses and hearing aids can help improve communication, orientation, and awareness of surroundings.

Delirium is a serious change in mental abilities that results in confused thinking and a lack of awareness of one’s surroundings.It usually comes on fast and can be caused by various factors such as fever, infection, surgery, medication, or emotional distress.

Delirium can often be prevented.

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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?

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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?