Nokea
The client is experiencing delirium.
A nurse is collecting data from a client who is experiencing delirium. Which of the following findings should the nurse expect?
- A. Echopraxia
- B. Aphasia
- C. Acute onset of confusion
- D. Inability to read
Correct Answer: C
Rationale: Acute onset of confusion is a hallmark of delirium.
You may also like to solve these questions
A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?
- A. Decreased blood pressure
- B. Decreased skin turgor
- C. Weight loss
- D. Crackles heard in the lungs
Correct Answer: D
Rationale: Crackles in the lungs indicate fluid overload from excessive enteral feeding.
The child has ADHD and is taking methylphenidate.
A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?
- A. Our child has increased his daily caloric intake.
- B. Our child has a better grasp of reality.
- C. Our child has lost some weight since his last appointment.
- D. Our child is able to complete his homework on time.
Correct Answer: D
Rationale: Improved focus and task completion indicate methylphenidate's effectiveness.
The client reports he has headaches after taking chewable isosorbide dinitrate.
A nurse is caring for a client who reports he has headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse make?
- A. Swallow the tablet whole to minimize your headaches.
- B. You can discontinue the medication until the headache goes away.
- C. You should take the medication on an empty stomach to prevent a headache.
- D. The headaches should decrease as you get used to the medication.
Correct Answer: D
Rationale: Headaches are a common side effect of isosorbide that typically lessen over time.
The client is at 34 weeks of gestation.
A nurse is caring for a client who is at 34 weeks of gestation. Which of the following statements by the client is the nurse's priority to report to the provider?
- A. My heart feels like it skips a beat.
- B. I have nosebleeds once per week.
- C. The palms of my hands are red and blotchy.
- D. I'm experiencing persistent headaches.
Correct Answer: D
Rationale: Persistent headaches at 34 weeks may indicate preeclampsia, a priority concern.
A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?
- A. Diminished pulses on the affected extremity
- B. Ecchymosis on the inner left thigh
- C. Client report of muscle spasms of the left leg
- D. One fingerbreadth of space between the cast and the skin
Correct Answer: A
Rationale: Diminished pulses suggest vascular compromise, a priority concern.