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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E","dropdown-group-3":"A"}
Explanation
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Dyspnea: Dyspnea, or difficulty breathing, can be a symptom of an adverse reaction such as an allergic reaction, anaphylaxis, or cardiovascular issues. It indicates a severe reaction that affects the respiratory system and requires immediate attention.
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Nausea: Nausea is a common symptom of adverse reactions to medications or other substances. It can accompany other symptoms like dizziness or headache and indicates that the client is experiencing an ongoing negative reaction to a treatment or exposure.
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Headache: A headache can be a manifestation of various adverse reactions, including those related to medication or changes in blood pressure. It is a significant symptom that may indicate worsening of the client's condition or an ongoing adverse reaction that needs to be addressed.
Correct Answer is C
Explanation
A. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect
catheterized specimens: This instruction is incorrect for a 24-hour urine collection. Catheterized specimens are not typically used for creatinine clearance tests, and the nurse should not be notified when the bladder is full.
B. Urinate immediately into a urinal, and the lab will collect the specimen every 6 hours for the next 24 hours: This instruction is incorrect for a 24-hour urine collection. Creatinine clearance
tests require collection of all urine produced over a 24-hour period, not just specimens at specific intervals.
C. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours: This is the correct instruction for a 24-hour urine collection. The client should begin by discarding the first voided urine and then collect all subsequent urine produced over the next 24 hours, including the urine from the specified time.
D. Cleanse around the meatus, discard the first portion of voiding, and collect the rest in a sterile bottle: This instruction is not appropriate for a 24-hour urine collection. It describes a procedure for collecting a clean-catch urine sample, which is different from a 24-hour urine collection for creatinine clearance.
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