The nurse is caring for an older client with that is exhibiting signs of confusion. Which intervention should the nurse implement?
Offer water to the client hourly.
Reduce dairy product intake.
Increase daily sodium intake.
Review the intake and output record.
The Correct Answer is D
Choice A
Offering water to the client hourly is not appropriate. While staying hydrated is important for overall health, offering water hourly might not be necessary unless there is a specific indication of dehydration. However, monitoring the client's fluid intake and output is a good approach.
Choice B
Reducing dairy product intake is not appropriate. Dairy product intake is not typically associated with sudden onset confusion. Reducing dairy product intake would not be the primary intervention for addressing confusion.
Choice C
Increasing daily sodium intake is not appropriate. Increasing sodium intake is unlikely to be the appropriate intervention for confusion unless there is a specific medical reason for it. Moreover, excessive sodium intake can have negative health consequences.
Choice D
Reviewing the intake and output record is appropriate. Confusion in an older client can be caused by various factors, including medical conditions, medication side effects, dehydration, and electrolyte imbalances. Reviewing the intake and output record (option D) is a reasonable intervention to gather more information about the client's fluid balance and hydration status. This can help the nurse assess whether the confusion might be related to dehydration or electrolyte imbalances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Correct answer: D
Choice A
Urinary ketones are not most important. Monitoring urinary ketones can provide information about the utilization of glucose and fat as energy sources. However, it is not the primary lab value to monitor in TPN administration.
Choice B
Serum protein is not most important. Monitoring serum protein levels is important to assess nutritional status, but it might not be as immediate a concern as serum osmolarity.
Choice C
Serum osmolarity reflects the concentration of particles (such as electrolytes, glucose, and other solutes) in the blood. Monitoring serum osmolarity is importantto prevent complications related to fluid and electrolyte imbalances that can arise from the administration of TPN.Blood glucose levels (option D) are more critical because TPN can significantly impact glucose metabolism
Choice D
When caring for a client receiving total parenteral nutrition (TPN), the nurse’spriorityis tomonitor blood glucose levels. TPN can affect blood glucose, and observing for signs of hyperglycemia or hypoglycemia is crucial.Additionally, administering insulin as directed based on blood glucose levels is essential.
Correct Answer is B
Explanation
Choice A
Canned cream of mushroom soup, tuna salad, and water is inappropriate. Canned soups and processed foods like canned cream soups can be high in sodium. Tuna salad might also have added salt.
Choice B
B. Bacon, lettuce, and tomato sandwich, grapes, and skim milk is the appropriate selection. A serum sodium level of 155 mEq/L (155 mmol/L) is higher than the normal reference range (136 to 145 mEq/L or 136 to 145 mmol/L), indicating hypernatremia or high blood sodium levels. In this case, it's important for the client to choose foods that are lower in sodium to help manage their sodium intake.
Choice C
Taco salad, refried beans, low-fat ice cream, and coffee is inappropriate. Taco salad can contain salty ingredients, and refried beans can also be high in sodium. Processed meats and sauces used in tacos can contribute to sodium intake.
Choice D
Chicken salad on toast, fruit-flavoured yogurt, and iced tea is inappropriate. Chicken salad and some breads might contain added salt. Fruit-flavoured yogurts can also have added sugars, and iced tea can vary in sodium content depending on how it's prepared.
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