The primary caregiver of an older adult client calls the nurse at the outpatient clinic due to a sudden onset of changes in the client's behavior. The caregiver reports to the nurse that the client normally is oriented and able to answer questions but now is confused and agitated. What
action(s) should the nurse take? Select all that apply.

Ask if the client is experiencing any pain with urination.

Determine if the client has recently experienced a fall.

Provide instruction on taking the client's temperature.

Encourage increased intake of high protein foods.

Review the client's current food and medication allergies

Answer and Explanation

Correct Answer : A,B,C,E

A.   Ask if the client is experiencing any pain with urination. Urinary tract infections (UTIs) are common in older adults and can lead to sudden changes in behavior, including confusion and agitation.
B.   Determine if the client has recently experienced a fall. Falls can lead to head injuries or other trauma that may cause confusion or changes in behavior in older adults.
C.   Provide instruction on taking the client's temperature. Fever can be a sign of infection, which might be causing the sudden behavioral changes. Monitoring temperature can help identify if an infection is present.
D.   Encourage increased intake of high protein foods. While good nutrition is important, it is not directly related to the sudden onset of confusion and agitation, making this a less immediate priority.
E.   Review the client's current food and medication allergies. Allergic reactions to foods or
medications can cause sudden behavioral changes. Reviewing allergies can help determine if this is the cause of the symptoms.

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Correct Answer is C

Explanation

A. Right ear hearing loss. While significant, right ear hearing loss is not immediately life- threatening.
B. Difficulty with balance. Balance issues may be concerning but are not typically indicative of a life-threatening condition.
C. Intensifying headache. An intensifying headache can be a sign of increased intracranial pressure, which is a medical emergency and requires immediate attention.
D. Facial numbness. Facial numbness can indicate nerve involvement but is not as immediately concerning as an intensifying headache, which could indicate a serious neurological issue such as bleeding or swelling in the brain.

A. Measure the respiratory rate B. Palpate the abdomen C. Check the airway for patency D. Feel for a pulse E. Stabilize the cervical spine F. Call for an x-ray

Correct Answer is ["C","E"]

Explanation

A. Measure the respiratory rate

While important, measuring the respiratory rate is not the first priority in the primary survey of trauma assessment.
B. Palpate the abdomen

Palpating the abdomen is part of the secondary survey in trauma care, which comes after the primary survey and initial stabilization.
C. Check the airway for patency

The first step in the primary survey (ABCDE approach) is to check the airway to ensure it is patent. If the airway is not clear, the patient cannot breathe, and immediate intervention is needed.
D. Feel for a pulse

While checking circulation (which includes feeling for a pulse) is important, it comes after ensuring the airway and cervical spine are addressed.
E. Stabilize the cervical spine

In trauma patients, particularly those with falls or other significant mechanisms of injury, stabilizing the cervical spine is crucial to prevent potential spinal cord injury.
F. Call for an x-ray

Ordering imaging studies is important but is not part of the initial primary survey, which focuses on immediate life-threatening conditions.

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Exhibits

The nurse is implementing solutions to provide care.

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

The nurse determines that the client's is still having an adverse reaction resulting in symptoms of dropdown
, dropdown
 and dropdown

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Naxlex Comprehensive Predictor Exams

The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life-threatening and should be reported to the healthcare provider immediately?

Correct Answer is C

Explanation

The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance. The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse. For the primary survey, what 2 things should the nurse do first?

Correct Answer is ["C","E"]

Explanation

The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Exhibits Based on the client's status at 1400, the nurse should plan to do which of the following? Select all that apply.

In providing nursing care for a client after gastric endoscopy, which intervention should the nurse include in the post-procedure plan of care for commonly occurring problems?

The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?