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
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.
Ego integrity vs despair.
According to Erikson’s psychosocial theory, older adults face the challenge of looking back on their lives and evaluating their accomplishments and failures.
If they feel satisfied with their life course, they achieve a sense of ego integrity, which is a feeling of wholeness and coherence.
If they feel regretful or dissatisfied, they experience despair, which is a sense of hopelessness and bitterness.
Choice A is wrong because trust vs mistrust is the first stage of Erikson’s theory, which occurs in infancy.
It involves developing a basic sense of trust in oneself and others based on the quality of caregiving.
Choice B is wrong because generativity vs stagnation is the seventh stage of Erikson’s theory, which occurs in middle adulthood.
It involves contributing to society and the next generation through work, parenting, or other activities.
Choice D is wrong because identity vs role confusion is the fifth stage of Erikson’s theory, which occurs in adolescence.
It involves developing a stable and coherent sense of self and one’s role in society.
Normal ranges for Erikson’s stages are:.
• Trust vs mistrust: birth to 18 months.
• Autonomy vs shame and doubt: 18 months to 3 years.
• Initiative vs guilt: 3 to 6 years.
• Industry vs inferiority: 6 to 12 years.
• Identity vs role confusion: 12 to 18 years.
• Intimacy vs isolation: 18 to 40 years.
• Generativity vs stagnation: 40 to 65 years.
• Ego integrity vs despair: 65 years and older.
Correct Answer is D
Explanation
The correct answer isD.
All of the above.
The nurse should take all of the actions listed to provide effective pain management for the older adult client who has depression and chronic pain in his lower back.
• Choice Ais correct because assessing the pain using a valid and reliable pain scale is essential for determining the severity and impact of pain, as well as monitoring the response to treatment.
• Choice Bis correct because administering analgesic medications as prescribed can help reduce pain and improve function.
The nurse should also monitor for effectiveness and side effects, especially in older adults who may have altered drug metabolism, polypharmacy, and increased risk of adverse events.
• Choice Cis correct because providing non-pharmacological interventions can enhance pain relief, reduce medication use, and address the biopsychosocial aspects of pain.
Massage, heat or cold therapy, relaxation techniques, and distraction are some examples of non-pharmacological interventions that can be used for chronic pain in older adults.
• Choice Dis correct because it includes all of the above actions, which are part of a multimodal approach to pain management that is recommended by clinical guidelines.
4 7 A multimodal approach can improve pain outcomes, reduce side effects, and address the complex needs of older adults with chronic pain.
A. Assess the location, intensity, quality and duration of the pain using a pain scale B.
Administer analgesic medications as prescribed and monitor for effectiveness and side effects C.
Provide non-pharmacological interventions such as massage, heat or cold therapy, relaxation techniques or distraction D.
All of the above
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