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 B
Explanation
Choice A
Protein is not essential. While protein can influence blood sugar levels to some extent, its effect is much smaller compared to carbohydrates. Protein is not typically counted as a primary factor in insulin dosing.
Choice B
Carbohydrates are essential. For a client with type 1 diabetes mellitus who uses both short-acting (mealtime) and long-acting (basal) insulin, counting carbohydrates is essential for meal planning and insulin dosing. Carbohydrates have the most direct and significant impact on blood sugar levels. When carbohydrates are consumed, they are broken down into glucose, which enters the bloodstream and can lead to increased blood sugar levels
Choice C
Dairy is not essential. Dairy products can contain carbohydrates (such as lactose), but the carbohydrate content varies and is not as significant as in foods like grains, fruits, and starchy vegetables.
Choice D
Fats are not essential. Fats have minimal direct impact on blood sugar levels. However, they can affect the overall rate of digestion and absorption of carbohydrates, potentially influencing the timing of insulin administration. But carbohydrate counting remains the primary focus for insulin adjustment.
Correct Answer is A
Explanation
Choice A
Potatoes, bananas, and oranges should be encouraged. Hypokalaemia refers to a lower than normal level of potassium in the blood. Potassium is an essential mineral that plays a crucial role in maintaining proper muscle function, nerve signalling, and fluid balance in the body. To address hypokalaemia, it's important to consume foods that are rich in potassium.
Choice B
Cranberry juice, butter, and hard candy. None of these foods are particularly high in potassium should not be encouraged. Cranberry juice is more commonly associated with urinary tract health, and butter and hard candy do not contribute significant amounts of potassium.
Choice C
Milk products, canned salmon, and fresh oysters should not be encouraged. While milk products contain some potassium, they are not as potent a source as other options. Canned salmon and fresh oysters do provide some potassium, but they are not as well-known for their potassium content as other foods like bananas and potatoes.
Choice D
Hard cheese, whole grain cereals, and dried vegetables should not be encouraged. These foods are not known for being particularly high in potassium. Hard cheese and whole grain cereals have limited potassium content, and dried vegetables, while containing some potassium, are not among the best sources.
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