Nokea
When communicating with a patient who is experiencing delirium, what is the nurse's priority?
- A. Use complex language to explain the patient's condition.
- B. Provide clear and simple explanations to minimize confusion.
- C. Ignore the patient's confusion and proceed with the conversation.
- D. Speak loudly to ensure the patient can hear.
Correct Answer: B
Rationale: When communicating with a patient experiencing delirium, the nurse's priority is to provide clear and simple explanations to minimize confusion. Delirium can cause disorientation, confusion, and impaired cognitive function, making it difficult for the patient to understand complex information. Using simple language and clear explanations can help the patient better comprehend the situation and reduce anxiety. It is essential for the nurse to speak calmly, use reassuring gestures, and maintain a supportive presence to effectively communicate with a delirious patient. This approach can help establish a sense of trust and foster a therapeutic nurse-patient relationship during the challenging experience of delirium.
You may also like to solve these questions
A patient with a history of chronic obstructive pulmonary disease (COPD) is prescribed a metered-dose inhaler (MDI) with a spacer. Which instruction should the nurse include in the demonstration of MDI use?
- A. Inhale slowly and deeply while pressing the canister.
- B. Exhale completely before inhaling the medication.
- C. Shake the inhaler vigorously before each puff.
- D. Hold the breath for 10 seconds after inhaling the medication.
Correct Answer: A
Rationale: The correct instruction for using a metered-dose inhaler (MDI) with a spacer for a patient with COPD is to inhale slowly and deeply while pressing the canister. This technique helps ensure that the medication reaches the lungs effectively. Inhaling slowly and deeply allows the medication to be properly delivered to the airways, maximizing its effectiveness in treating the symptoms of COPD. This instruction helps the patient coordinate pressing the canister with their inhalation, which is crucial for proper medication delivery in COPD management.
A patient presents with sudden-onset severe scrotal pain, swelling, and erythema. Physical examination reveals a tender, swollen, and high-riding testicle. What is the most likely diagnosis?
- A. Testicular torsion
- B. Epididymitis
- C. Testicular trauma
- D. Testicular tumor
Correct Answer: A
Rationale: Given the sudden-onset severe scrotal pain, swelling, and erythema, along with the physical examination findings of a tender, swollen, and high-riding testicle, the most likely diagnosis is testicular torsion. Testicular torsion occurs when the spermatic cord twists, leading to compromised blood flow to the testicle, causing ischemia and severe pain. It is considered a surgical emergency that requires prompt diagnosis and intervention to salvage the affected testicle. Prompt surgical detorsion is necessary to prevent irreversible testicular damage. While epididymitis, testicular trauma, and testicular tumors can also present with scrotal pain and swelling, the presence of a high-riding testicle in this context is highly suggestive of testicular torsion.
A patient with chronic kidney disease presents with metabolic acidosis. Which compensatory mechanism is the body most likely to employ to normalize pH?
- A. Hyperventilation
- B. Increased bicarbonate reabsorption
- C. Increased renal excretion of hydrogen ions
- D. Decreased renal excretion of bicarbonate ions
Correct Answer: B
Rationale: In a patient with chronic kidney disease presenting with metabolic acidosis, the compensatory mechanism the body is most likely to employ to normalize pH is increased bicarbonate reabsorption in the kidneys. The kidneys play a crucial role in maintaining acid-base balance by regulating bicarbonate levels in the blood. In metabolic acidosis, there is an excess of non-volatile acids in the body, leading to a decrease in blood pH. To compensate for this acidosis, the kidneys increase the reabsorption of filtered bicarbonate ions from the renal tubules back into the blood. This process helps to raise the bicarbonate levels in the blood, which in turn helps to neutralize excess hydrogen ions and restore the blood pH towards normal levels. Hyperventilation (A) is a compensatory mechanism for respiratory acidosis, not metabolic acidosis. Increased renal excretion of hydrogen ions (C) and decreased renal excretion of bicarbonate ions
A patient with chronic kidney disease presents with periorbital edema, hypertension, and proteinuria. Laboratory findings reveal elevated serum creatinine and urea levels, hyperkalemia, and metabolic acidosis. What is the most likely diagnosis?
- A. Nephrotic syndrome
- B. Diabetic nephropathy
- C. Acute glomerulonephritis
- D. Chronic kidney disease (CKD)
Correct Answer: D
Rationale: The constellation of symptoms presented (periorbital edema, hypertension, proteinuria) along with the laboratory findings (elevated creatinine and urea levels, hyperkalemia, metabolic acidosis) are classical signs of chronic kidney disease (CKD). In CKD, the kidneys gradually lose their function over time, leading to impaired filtration of waste products and electrolyte imbalance. The presence of hypertension and proteinuria are common in CKD due to the compromised renal function. Additionally, elevated serum creatinine and urea levels, hyperkalemia, and metabolic acidosis are indicative of kidney dysfunction.
It is 10 o'clock of your watch. The client asks, "What time is it?" The nurse's appropriate response is:
- A. "Are you bored?"
- B. "It is 10 o'clock.".
- C. "Why do you ask?"
- D. "Guess, what time is it?"
Correct Answer: B
Rationale: The nurse's appropriate response is to provide the requested information clearly and directly. In this case, the client asked for the time, so the best response is to say "It is 10 o'clock" to answer their question promptly. Options A, C, and D do not address the client's question and may be perceived as dismissive or unhelpful.