Nokea
The client is disoriented and restless.
A nurse is assisting with the care of a client who has delirium. The client is disoriented and restless. Which of the following conditions should the nurse identify as a risk factor for delirium?
- A. Hypersomnia
- B. High cholesterol
- C. Urinary tract infection
- D. Amyloid plaque
Correct Answer: C
Rationale: Urinary tract infections are a common delirium risk factor, especially in older adults.
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The client consumed alcohol 2 days after taking disulfiram.
A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?
- A. Constipation
- B. Dry skin
- C. Hypotension
- D. Urinary retention
Correct Answer: C
Rationale: Disulfiram-alcohol reaction causes hypotension among other symptoms.
The client expresses anxiety about exercising in the outdoor courtyard.
A nurse in a mental health facility is caring for a client who expresses anxiety about exercising in the outdoor courtyard. The nurse promises to walk with the client in the courtyard each day. Which of the following ethical principles is the nurse demonstrating?
- A. Fidelity
- B. Justice
- C. Nonmaleficence
- D. Autonomy
Correct Answer: A
Rationale: Fidelity is demonstrated by keeping the promise to walk with the client.
A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?
- A. Offer the client several choices at mealtimes.
- B. Alternate daily caregivers.
- C. Avoid discussing the client's fears.
- D. Remind the client of the day and time often.
Correct Answer: D
Rationale: Frequent orientation to time reduces confusion in delirium.
The client's prescription for erythromycin 500 mg four times per day.
A nurse is transcribing a client's prescription for erythromycin 500 mg four times per day. Which of the following information should the nurse clarify with the provider?
- A. Medication
- B. Dosage
- C. Route
- D. Time
Correct Answer: C
Rationale: The route (e.g., PO, IV) is unspecified and requires clarification.
The client has heart failure and is taking furosemide.
A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?
- A. Increased urinary output
- B. Decreased hemoglobin level
- C. Increased weight of 0.91 kg (2 lb)
- D. Decreased BUN level
Correct Answer: A
Rationale: Increased urinary output reflects furosemide's diuretic effect, reducing fluid overload.