Nokea
A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium?
- A. Fluctuating level of orientation.
- B. Consistent state of depression.
- C. Demonstrates obsessive behaviors.
- D. Short-term memory loss.
Correct Answer: A
Rationale: A fluctuating level of orientation is a hallmark sign of delirium. Delirium is characterized by an acute and fluctuating course of altered mental status, including changes in attention and cognition, distinguishing it from depression or dementia.
You may also like to solve these questions
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 participating in a community program about eating disorders. Which of the following information about bulimia nervosa should the nurse include in the presentation?
- A. People who have bulimia nervosa are at risk for developing diabetes mellitus.
- B. Bulimia nervosa is difficult to notice because a person might be of average or ideal body weight.
- C. People who have bulimia nervosa eat an average amount of food on a daily basis.
- D. As long as a person is not vomiting after eating, they do not have bulimia nervosa.
Correct Answer: B
Rationale: Individuals with bulimia nervosa often maintain an average or ideal body weight, making the disorder less visible. This highlights a key characteristic for community education.
A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide?
- A. Currently married.
- B. Access to guns in the home.
- C. Terminal liver cancer.
- D. Alcohol use disorder.
Correct Answer: B,C,D
Rationale: Access to guns in the home, terminal liver cancer, and alcohol use disorder are significant risk factors for suicide. Guns increase lethality, terminal illness causes distress, and alcohol impairs judgment and increases impulsivity, all elevating suicide risk.
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.
A nurse is caring for multiple clients on a mental health unit. Which of the following clients should the nurse attend to first?
- A. A client who is repeatedly approaching the nurses' station to request medication for his anxiety.
- B. A client who is standing in her room, yelling obscenities, and throwing her clothes.
- C. A client who has bipolar disorder and is continuously pacing at the end of the hall.
- D. A client in the dayroom who is screaming at other clients about what is on the television.
Correct Answer: B
Rationale: A client yelling obscenities and throwing clothes poses a more direct risk due to potential escalation to physical harm. This behavior requires immediate attention over anxiety, pacing, or verbal disruptions.