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 A

Explanation

A. Leave the room and close the door quietly. Respecting the client's privacy is essential. The nurse should leave the room quietly and return later to administer the medication.
B. Ignore the behavior and hang the IV antibiotic. Ignoring the behavior and proceeding with the medication administration would violate the client's privacy.
C. Complete an unusual occurrence report. This situation does not require an incident report; it is a private matter between the client and the visitor.
D. Tell the client to stop the inappropriate behavior. The behavior is not necessarily inappropriate within the context of the client's rights to privacy and intimacy.

Correct Answer is []

Explanation

Immunological Administer antihistamine
The correct answer is to administer antihistamine. Antihistamines can help alleviate symptoms of an allergic reaction, such as itching, hives, and swelling, by blocking the effects of histamine
released during the allergic response.

Cardiovascular

Monitor vital signs continuously

The correct answer is to monitor vital signs continuously. Continuous monitoring of vital signs, including blood pressure, heart rate, and oxygen saturation, is essential to detect any changes in the client's cardiovascular status, especially after experiencing adverse reactions to medication.

Provide warmth

Providing warmth can help improve peripheral circulation and comfort for the client, especially if they are experiencing symptoms such as dizziness or feeling cold due to a drop in blood pressure.

Respiratory

Assess lung sounds

The correct answer is to assess lung sounds. Assessing lung sounds can help determine if the client is experiencing any respiratory distress or complications, such as wheezing or crackles, which may indicate a need for further intervention or respiratory support.

Chest x-ray

Ordering a chest x-ray can help evaluate the client's respiratory status, especially if there are concerns about potential complications such as pneumonia or pulmonary edema. It allows for the assessment of lung fields and can provide valuable information about the client's respiratory function.

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Naxlex Comprehensive Predictor Exams

When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement?

Correct Answer is A

Explanation

Correct Answer is []

Explanation

Exhibits Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

A client with a right hemopneumothorax has a chest tube connected to suction. While turning to the left side, the client becomes suddenly short of breath and anxious. Which intervention should the nurse implement?

The nurse is providing postoperative care for an adolescent who had an amputation of the left leg for osteosarcoma. The adolescent describes experiencing phantom limb pain. Which non pharmacological intervention should the nurse provide?

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

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A client with chronic obstructive pulmonary disease (COPD) receives a prescription for chest physiotherapy (CPT) to help mobilize secretions. Following the therapy, which finding indicates to the nurse that the intervention was effective?