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 D

Explanation

A. A blood glucose level of 90 mg/dL is within the normal reference range of 74 to 106 mg/dL, so it is not a concern.
B. A potassium level of 4 mEq/L is also within the normal reference range of 3.5 to 5.0 mEq/L, so it does not need to be reported.
C. Although the hemoglobin level of 13 g/dL is below the reference range provided, it is not critically low and may not be urgent unless the patient has symptoms of anemia or other related issues.
D. A serum creatinine level of 5 mg/dL is significantly higher than the normal reference range of 0.5 to 1.1 mg/dL. This indicates renal impairment, which could affect the patient's ability to clear medications used during surgery and could lead to postoperative complications. Therefore, it is crucial to report this finding to the surgeon immediately.

A. Provide a list of alternative activities that are less likely to cause the child to experience fatigue. B. Suggest that the child be encouraged to participate in a team sport to encourage socialization. C. Explain that their child is too young to understand the risks associated with swimming. D. Encourage the parents to allow the child to continue attending swimming lessons with supervision.

Correct Answer is D

Explanation

- A: Providing a list of alternative activities may reduce fatigue, but it does not consider the child's interest in swimming, which can be therapeutic and enjoyable for children with Duchenne muscular dystrophy.
- B: While team sports can be good for socialization, they may not be suitable for a child with Duchenne muscular dystrophy due to the progressive muscle weakness associated with the condition, which could lead to increased risk of injury.
- C: At the age of 6, children are capable of understanding basic risks, and it is important to communicate with them appropriately rather than assuming they are too young. Moreover, swimming can be adapted to be safe for children with physical limitations.
- D: Swimming is an excellent activity for children with Duchenne muscular dystrophy because it is low-impact and can help maintain muscle strength and function. With proper supervision and precautions, the risks can be managed, making it a suitable activity for the child to continue.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

Correct Answer is D

Explanation

The nurse is collecting a heelstick blood specimen for a neonatal screen, which includes thyroxine (T4) and thyroid stimulating hormone (TSH) levels, prior to the discharge of a 2-day- old client. When the parents ask why these tests are being conducted, which explanation should the nurse provide?

The nurse observes an unlicensed assistive personnel (UAP) who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. Which action should the nurse take?

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

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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.

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.

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?