The primary caregiver of an elderly patient contacts the nurse at the outpatient clinic due to a sudden change in the patient’s behavior.
The caregiver informs the nurse that the patient, who is usually oriented and able to answer Questions, is now confused and agitated.
What actions should the nurse take? (Select all that apply)
Inquire if the patient is experiencing any pain during urination.
Encourage the patient to increase their intake of high-protein foods.
Review the patient’s current food and medication allergies.
Determine if the patient has recently experienced a fall.
Provide instructions on how to take the patient’s temperature.
Correct Answer : A,C,D,E
Choice A rationale
A sudden change in behavior, especially confusion and agitation, in an elderly patient could be a sign of a urinary tract infection (UTI). Pain during urination is a common symptom of UTIs.
Therefore, it is crucial to inquire if the patient is experiencing any pain during urination.
Choice B rationale
While a high-protein diet can be beneficial for some patients, there is no direct link between increased protein intake and the alleviation of confusion or agitation in elderly patients.
Therefore, this option is not a necessary immediate action for the nurse to take.
Choice C rationale
Reviewing the patient’s current food and medication allergies is important. Certain medications or foods might cause adverse reactions, including confusion and agitation. Therefore, it is crucial to review the patient’s allergies to rule out any potential allergens as the cause of the sudden change in behavior.
Choice D rationale
A recent fall could potentially lead to a head injury, which might cause confusion and agitation. Therefore, it is important to determine if the patient has recently experienced a fall.
Choice E rationale
Providing instructions on how to take the patient’s temperature is important. Fever could be a sign of an infection or other medical condition that might cause confusion and agitation.
Therefore, knowing how to accurately measure the patient’s temperature can help monitor the patient’s condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While a case management evaluation of the client’s home environment could potentially identify areas for improvement, it may not directly address the caregiver’s immediate need for relief from their caregiving responsibilities. The caregiver is experiencing sleepless nights and frequent bouts of crying, which could be signs of caregiver burnout or depression. Therefore, immediate respite care may be more beneficial.
Choice B rationale
Employing a private duty nurse for respite could provide temporary relief for the caregiver. However, this option might not be feasible due to potential financial constraints. Additionally, it may not provide the caregiver with the emotional support they may need.
Choice C rationale
Proposing that extended family could relocate to the area to provide support is a potential long-term solution. However, it may not be feasible or practical for extended family members to relocate. This option also does not address the caregiver’s immediate need for relief and support.
Choice D rationale
Advising the caregiver to contact social services to locate a respite care facility for the client could provide the caregiver with the immediate relief they need. Respite care facilities offer temporary relief for caregivers by providing short-term care for the individual they are caring for. This would allow the caregiver to rest and take care of their own needs, which could help alleviate their symptoms of sleepless nights and frequent bouts of crying.
Correct Answer is B
Explanation
Choice A rationale
Osteoarthritis is a type of arthritis that occurs when the cartilage that cushions the ends of your bones in your joints gradually deteriorates. Osteoarthritis symptoms often develop slowly and worsen over time. They can include: Pain in the joint during or after use, or after periods of inactivity, Tenderness in the joint when you apply light pressure to or near it, Stiffness in the joint, that may be most noticeable when you wake up in the morning or after a period of inactivity, Loss of flexibility in the joint, Grating sensation or sound when you use the joint. But in this case, the client’s symptoms do not align with those of osteoarthritis.
Choice B rationale
Rheumatoid Arthritis is a chronic inflammatory disorder that can affect more than just your joints. In some people, the condition can damage a wide variety of body systems, including the skin, eyes, lungs, heart and blood vessels. Signs and symptoms of rheumatoid arthritis may include: Tender, warm, swollen joints, Joint stiffness that is usually worse in the mornings and after inactivity, Fatigue, fever and loss of appetite. The client’s symptoms align with those of Rheumatoid Arthritis.
Choice C rationale
Carpal Tunnel Syndrome is a condition that causes numbness, tingling and other symptoms in the hand and arm. Carpal tunnel syndrome is caused by a compressed nerve in the carpal tunnel, a narrow passageway on the palm side of your wrist. The anatomy of your wrist, health problems and possibly repetitive hand motions can contribute to carpal tunnel syndrome. But in this case, the client’s symptoms do not align with those of Carpal Tunnel Syndrome.
Choice D rationale
Gout is a common and complex form of arthritis that can affect anyone. It’s characterized by sudden, severe attacks of pain, swelling, redness and tenderness in the joints, often the joint at the base of the big toe. An attack of gout can occur suddenly, often waking you up in the middle of the night with the sensation that your big toe is on fire. The affected joint is hot, swollen and so tender that even the weight of the sheet on it may seem intolerable. But in this case, the client’s symptoms do not align with those of Gout.
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