Nokea
An 80-year-old patient is placed in isolation when infected with methicillin-resistant Staphylococcus aureus. The patient was alert and oriented on admission, but is now having visual hallucinations and can follow only simple directions. The medical-surgical nurse recognizes that the changes in the patient's mental status are related to
- A. a fluid and electrolyte imbalance.
- B. a stimulating environment.
- C. sensory deprivation.
- D. sundowning.
Correct Answer: C
Rationale: Isolation can lead to sensory deprivation, affecting cognitive function.
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Identify the five rights of delegating nursing care (select all that apply).
- A. Right time
- B. Right task
- C. Right patient
- D. Right person
Correct Answer: B
Rationale: Effective delegation involves the right task, patient, person, circumstance, and supervision/evaluation.
Which type of stress helps individuals pursue goals and solve problems?
- A. Energy stress
- B. Active stress
- C. Eustress
- D. Distress
Correct Answer: C
Rationale: Eustress is positive stress that motivates individuals to achieve goals, learn new skills, and manage crises effectively.
Joan is apprehensive about undergoing bronchoscopy. You respond by saying
- A. The thought of this procedure seems to be disturbing you. You will be sleeping during this procedure. I will ask your physician to visit you again and answer any questions that you might have regarding the procedure.
- B. Your physician has performed this procedure frequently.
- C. I had it performed 3 years ago and I was fine.
- D. You would not feel a thing. You will be fine.
Correct Answer: A
Rationale: Option A provides emotional support, reassurance, and an opportunity for further clarification, which is essential in reducing patient anxiety.
How can a nurse provide culturally competent care to all individuals?
- A. Become familiar with physical differences among ethnic groups.
- B. Learn to speak a second language.
- C. Develop strategies to avoid cultural imposition.
- D. Consult the client about ways to solve health problems.
Correct Answer: C
Rationale: Avoiding cultural imposition ensures respect for individual preferences and promotes inclusive care practices.
During an assessment in the emergency department, an older adult client with community-acquired pneumonia is found to be confused. Which of the following findings should the nurse expect?
- A. Unequal pupils
- B. Hypertension
- C. Tympany upon chest percussion
- D. Confusion
Correct Answer: D
Rationale: The correct answer is D: Confusion. Confusion in an older adult with community-acquired pneumonia can indicate hypoxia or sepsis affecting the brain. It is a common manifestation in elderly patients with pneumonia due to impaired gas exchange and systemic inflammatory response. Unequal pupils do not typically relate to pneumonia. Hypertension is not a common finding in pneumonia; hypotension is more likely. Tympany upon chest percussion is associated with conditions like pneumothorax, not pneumonia. Therefore, confusion is the most relevant finding in this scenario.