Nokea
A nurse is assisting with the care of a client who has dementia. Which of the following actions should the nurse take?
- A. Provide the client with a dark environment for sleeping.
- B. Repeat orientation tasks until the client gives a correct response.
- C. Give the client a list of foods to choose from for dinner.
- D. Make a personal introduction to the client at each interaction.
Correct Answer: D
Rationale: Making a personal introduction at each interaction helps establish connection and reduce confusion for clients with dementia, who often have short-term memory loss.
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A nurse is caring for a client who has an opioid use disorder. The nurse should anticipate that the provider will prescribe which of the following medications for treatment?
- A. Phenobarbital.
- B. Diazepam.
- C. Chlordiazepoxide.
- D. Buprenorphine.
Correct Answer: D
Rationale: Buprenorphine is a partial opioid agonist used in medication-assisted treatment for opioid use disorder, helping to reduce cravings and withdrawal symptoms. It’s specifically indicated for this condition.
Nurses' Notes
0205: Client brought to the ED by police after being found wandering on the street. Client able to provide identity to police but not able to identify place or time. Family notified. Client confused and agitated. Appearance is disheveled. Mucous membranes dry. Lungs clear and equal, heart rhythm regular. During data collection, client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.
0415: Client's adult child arrived to the ED and went to client's room. Client identified family member. Client is pacing and agitated, and states, "I don't understand why I am here." Adult child asks nurse to talk outside of room and states, "I don't know why they are so confused. They are not normally like this." Adult child states client has past medical history of hypertension and alcohol-related cirrhosis. Upon returning to room, client voided 250 mL of dark yellow, cloudy urine.
Vital Signs
0200:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 104/min
• Respiratory rate: 18/min
• Blood pressure: 158/96 mm Hg
• Oxygen saturation: 98% on room air
0415:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 108/min
• Respiratory rate: 20/min
• Blood pressure: 148/94 mm Hg
• Oxygen saturation: 98% on room air
Provider's Note
0230: Client diagnosis: delirium secondary to a urinary tract infection and dehydration. Will transfer client to medical-surgical unit.
Laboratory Results
0230:
• Serum toxicology screen: Alcohol: 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
A nurse is caring for a 65-year-old male client in the emergency department (ED).For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.
- A. Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.
- B. Administer lorazepam.
- C. Initiate 1:1 supervision.
- D. Administer acyclovir.
Correct Answer: A,B,C
Rationale: IV fluids address dehydration, lorazepam manages agitation or withdrawal, and 1:1 supervision ensures safety due to delirium. Acyclovir is unexpected as no viral infection is indicated.
Nurses' Notes
0230:
• Serum toxicology screen: Alcohol: 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
Vital Signs
0200:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 104/min
• Respiratory rate: 18/min
• Blood pressure: 158/96 mm Hg
• Oxygen saturation: 98% on room air
0415:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 108/min
• Respiratory rate: 20/min
• Blood pressure: 148/94 mm Hg
• Oxygen saturation: 98% on room air
Provider's Note
0230: Client diagnosis: delirium secondary to a urinary tract infection and dehydration. Will transfer client to medical-surgical unit.
Laboratory Results
0230:
• Serum toxicology screen: Alcohol: 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
A nurse is caring for a 65-year-old male client in the emergency department (ED). Which of the following interventions should the nurse include in the client's care? Select the 3 interventions the nurse should implement.
- A. Maintain a low stimulation environment.
- B. Alternate nursing staff daily.
- C. Provide client with limited information about diagnosis.
- D. Approach client slowly.
- E. Reorient client to person, place, and time frequently.
Correct Answer: A,D,E
Rationale: Maintaining a low stimulation environment, approaching slowly, and frequent reorientation address delirium symptoms by reducing agitation, building trust, and improving orientation, based on the client’s confused state.
A nurse is reinforcing behavior management techniques with the parent of a school-age child who has conduct disorder. Which of the following statements by the parent indicates an understanding of the redirection technique?
- A. I should use role-playing to enhance new behavioral skills.
- B. I should move closer to my child when they are agitated.
- C. I should ignore attention-seeking behaviors.
- D. I should re-engage my child in an appropriate activity.
Correct Answer: D
Rationale: Re-engaging the child in an appropriate activity is a key part of the redirection technique. It helps divert the child's attention away from the undesired behavior and encourages positive behavior, showing the parent understands this approach.
A client is becoming increasingly agitated
- A. anxious
- B. and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?
- C. Verbally de-escalate the client.
- D. Take the client to the seclusion room.
- E. Place the client in restraints.
- F. Obtain a prescription for haloperidol.
Correct Answer: A
Rationale: Verbally de-escalating the client is the first step to reduce agitation and prevent escalation. This non-invasive approach prioritizes safety and communication.