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A client admitted to the medical surgical unit was recently weaned from the mechanical ventilator and an IV infusion of lorazepam. The client has been alert and oriented for 24 hours but is now experiencing confusion. The practical nurse assists the registered nurse with the evaluation of new-onset confusion by assessing the client's sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy. The practical nurse suspects which condition in this client?
- A. Amnesia
- B. Delirium
- C. Dementia
- D. Psychosis
Correct Answer: B
Rationale: New-onset confusion with disorientation, difficulty focusing, memory loss, and lethargy post-ventilation and lorazepam suggests delirium , often seen in ICU patients due to medication withdrawal or critical illness. Amnesia , dementia , and psychosis have different presentations.
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The physician has prescribed Elavil(amitriptyline) for a client with depression. The nurse should continue to monitor the client's mood because the maximal effects of tricyclic antidepressant medication does not occur for:
- A. $48-72$ hours
- B. 5-7 days
- C. 2-4 weeks
- D. 3-6 months
Correct Answer: C
Rationale: Tricyclic antidepressants like amitriptyline take 2-4 weeks to reach maximal therapeutic effect. Choices A and B are too short, and D is excessively long.
A client diagnosed with cirrhosis is started on lactulose (Cephulac). The main purpose of the drug for this client is to
- A. add dietary fiber
- B. reduce ammonia levels
- C. stimulate peristalsis
- D. control portal hypertension
Correct Answer: B
Rationale: Lactulose blocks the absorption of ammonia from the GI tract and secondarily stimulates bowel elimination.
Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
- A. Crying
- B. Wakefulness
- C. Jitteriness
- D. Yawning
Correct Answer: C
Rationale: Jitteriness in a newborn of a diabetic mother may indicate hypoglycemia, requiring immediate intervention. Crying, wakefulness, and yawning are normal behaviors, so A, B, and D are incorrect.
The nurse is speaking with the parent of a toddler who believes the child has a hearing deficit. Which findings support this suspected diagnosis? Select all that apply.
- A. Behavior appears withdrawn
- B. Inintelligible speech began at age 12 months
- C. Monotone speech
- D. Seems attentive, nods, and smiles when given directions
- E. Speaks with a loud voice
Correct Answer: A,C,E
Rationale: Signs of hearing deficit in a toddler include withdrawn behavior , monotone speech , and loud speech due to inability to modulate voice. Inintelligible speech at 12 months is normal, and attentiveness suggests intact hearing.
A 72-year-old woman is being treated for pneumonia. Physician's orders include an antibiotic, oxygen PRN for O2 saturation less than 90, and pulse oximetry every 4 hours. The nurse obtains a pulse oximetry reading of 82% on room air. What is the best action for the nurse to take?
- A. Report the finding to the physician
- B. Report the finding to the registered nurse to get instructions
- C. Start supplemental oxygen
- D. Start oxygen and repeat the pulse oximetry in 20 minutes
Correct Answer: C
Rationale: An O2 saturation of 82% requires immediate supplemental oxygen per orders to correct hypoxia, the priority action.