Nokea
A male client is admitted to the unit with a possible diagnosis of delirium. Which statement by the client's wife best supports the diagnosis?
- A. Since his mother died, he has not been feeling well.
- B. My husband just didn't seem to know what he was doing. He has been forgetful for years.
- C. The changes in his behavior came on so quickly! I wasn't sure what was happening.
- D. This is supposed to happen when you get old, right?
Correct Answer: C
Rationale: The correct answer is C because delirium is characterized by a rapid onset of confusion, changes in behavior, and altered mental status. The wife's statement about the changes in behavior coming on quickly aligns with this key characteristic of delirium.
Choice A is incorrect because the client's feelings after his mother's death are not necessarily related to delirium. Choice B is incorrect because long-term forgetfulness is more indicative of dementia rather than delirium. Choice D is incorrect because delirium is not a normal part of aging.
You may also like to solve these questions
A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)
- A. Weigh the client every 3 to 4 days.
- B. Discourage the client from taking a nap during the day.
- C. Monitor vital signs throughout the day.
- D. Offer nutritional foods to the client every 2 hours.
- E. Maintain an environment with low stimuli.
Correct Answer: B,C,D,E
Rationale: The correct interventions are B, C, D, and E. B: Discouraging naps helps regulate sleep patterns in mania. C: Monitoring vital signs is crucial due to potential physical risks. D: Offering frequent, nutritional foods helps stabilize energy levels. E: Low-stimuli environment reduces agitation. A is incorrect as frequent weighing may not be necessary. F and G are not provided but would be incorrect if they do not align with managing mania symptoms.
Charles, the nurse, is working in an emergency department and is assessing a preschool-age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse (select all that apply)
- A. Areas of ecchymosis on the torso.
- B. Mismatched clothing
- C. Abrasions on knees
- D. Abdominal rebound tenderness
- E. Round burn marks on forearms
Correct Answer: A,E
Rationale: The correct answers are A and E. Ecchymosis on the torso may indicate physical abuse, and burn marks on the forearms suggest possible abuse as well. Mismatched clothing (B) is not a direct indicator of abuse but may suggest neglect. Abrasions on knees (C) are common in preschool-age children and do not specifically point to abuse. Abdominal rebound tenderness (D) is a medical finding that may indicate a health issue but does not directly correlate with abuse. Overall, A and E are the most concerning findings that should alert the nurse to possible abuse.
A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan?
- A. Hyperextend the client's neck.
- B. Instruct the client to deep breathe every 4 hr.
- C. Place the head of the client's bed in the flat position.
- D. Check the client's voice every 2 hr.
Correct Answer: B,D
Rationale: The correct answers are B and D. Instructing the client to deep breathe every 4 hours helps prevent respiratory complications post-thyroidectomy. Checking the client's voice every 2 hours is important to monitor for vocal cord damage, a potential complication. Choice A is incorrect as hyperextending the client's neck can put strain on the surgical site. Choice C is incorrect as the head of the bed should be elevated to reduce swelling and promote drainage.
A nurse is caring for a postoperative client following a total knee replacement. Which of the following medications should the nurse anticipate the provider to prescribe to prevent the formulation of a deep vein thrombosis (DVT)?
- A. Enoxaparin
- B. Alteplase (tPA)
- C. Warfarin
- D. Clopidogrel
Correct Answer: A
Rationale: The correct answer is A: Enoxaparin. Enoxaparin is a low molecular weight heparin that helps prevent deep vein thrombosis (DVT) by inhibiting clot formation. It is commonly prescribed postoperatively for clients undergoing knee replacement surgery due to the increased risk of DVT. Alteplase (tPA) is a thrombolytic agent used to dissolve existing blood clots and not typically used for prevention. Warfarin is an oral anticoagulant that requires monitoring of INR levels and is usually started after initial treatment with heparin. Clopidogrel is an antiplatelet agent and is not typically used for DVT prevention.
A nurse is reviewing the history and physical of an adolescent client diagnosed with conduct disorder. The nurse recognizes that which of the following is an expected assessment finding of conduct disorder?
- A. Death of client's father two months ago
- B. Experiences frequent facial tics
- C. Adheres strictly to routines
- D. Suspended from school several times in the past year
Correct Answer: D
Rationale: The correct answer is D: Suspended from school several times in the past year. Conduct disorder is characterized by persistent patterns of behavior that violate the rights of others and societal norms. Being suspended from school multiple times indicates a disregard for rules and authority, which is a common feature of conduct disorder. Choices A, B, and C do not directly align with the typical behaviors associated with conduct disorder. A recent death in the family (A) may lead to emotional distress but is not a defining characteristic of conduct disorder. Frequent facial tics (B) are more indicative of a neurological or psychological condition, not conduct disorder. Adhering strictly to routines (C) is more characteristic of obsessive-compulsive disorder, not conduct disorder.