The nurse is caring for a client with the following clinical data. Based on the clinical data, the nurse should clarify which order with the primary healthcare provider (PHCP)?
See the image below.
The nurse is caring for a client with the following clinical data. Based on the clinical data, the nurse should clarify which order with the primary healthcare provider (PHCP)?
See the image below.
A. Urine analysis (UA)
[4%]
B. Head CT Scan
[10%]
C. Regular diet
[78%]
D. Ammonia level
[9%]
Statistics
Subject/Lesson
Subject
Fundamentals
Lesson
Basic Care & Comfort
Client Need
Test Plan
Basic Care and Comfort
Related Topic
Nutrition and Oral Hydration
Item Type
Item Type
Analysis
Explanation
Choice C is correct. A regular diet prescription should be questioned because of the client's medical history of diabetes mellitus and hypertension. The appropriate diet would be one restricted in carbohydrates and sodium. Thus, the nurse should follow up with the PHCP regarding this order.
Choices A, B, and D are incorrect. A UA is a logical and plausible prescription for this client. Older adults may manifest infection as altered mental status. A CT scan should be obtained to rule out any structural abnormalities, such as infarcts. An ammonia level is useful to determine if the client has metabolic encephalopathy. The client has altered mental status, a cardinal feature of high ammonia levels.
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6 Key Topics
Carbohydrates
3.1 Macronutrients
Heart Healthy Diet
3.3 Therapeutic & Specialty Diets
Miscellaneous Diets
3.4 Dietary Restrictions & Progression
Additional Info
✓ AMS may be caused by many reasons, including infections such as neurosyphilis, cystitis, brain injury, dementia, delirium, or a psychiatry pathology.
✓ The nurse must implement measures to keep the client safe such as fall precautions. The client with altered mentation is at increased risk of falling and self-injury.
