Nokea
You are caring for an acute care adult client in the medical unit who has no history of a psychiatric mental health disorder. This 76 year old client has suddenly and abruptly started to exhibit episodic and intermittent periods of time vacillating between periods of impaired cognition and periods of mental clarity. The client reports to you that they are seeing clowns in their room. This client is dehydrated and has just begun taking an anticholinergic medication. Which of the following is the most appropriate nursing diagnosis for this client?
- A. Psychotic symptoms related to sensory overload
- B. Psychotic symptoms related to a previously undiagnosed psychosis
- C. Visual disturbances related to dementia
- D. Visual disturbances related to delirium
Correct Answer: D
Rationale: The sudden onset of impaired cognition, fluctuating mental status, and visual hallucinations in the context of dehydration and anticholinergic medication use strongly suggests delirium, not dementia or psychosis.
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The nurse is caring for a client who has just undergone a tonsillectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Encourage frequent swallowing.
- B. Monitor for excessive swallowing.
- C. Offer ice chips immediately.
- D. Keep the head of the bed flat.
Correct Answer: B
Rationale: Monitoring for excessive swallowing is critical post-tonsillectomy, as it may indicate bleeding from the surgical site.
The nurse instructs the client who is taking gentamicin to monitor factors related to renal function. The nurse determines that the client needs additional instruction when he makes which of the following statements?
- A. I should call you if I notice that I'm not urinating as much.'
- B. I should call you if my urine looks dark or unusual.'
- C. I should call you if my legs swell or I notice my skin looks puffy around my eyes.'
- D. I should call you if I have a fever.'
Correct Answer: D
Rationale: Gentamicin can cause nephrotoxicity, so monitoring for decreased urine output, dark urine, or edema (swelling) is appropriate. Fever is not directly related to renal function, indicating a need for further instruction.
A client who had a total knee replacement with a metal prosthesis is being prepared for discharge to home. Which statement by the client indicates to the nurse a need for further teaching?
- A. I can expect that changes in the shape of the knee will occur.
- B. I need to tell any future caregivers about the metal prosthesis.
- C. I need to report bleeding gums or tarry stools to the primary health care provider.
- D. I need to report fever, redness, or increased pain to the primary health care provider.
Correct Answer: A
Rationale: After a total knee replacement, the client should be taught to report any changes in the shape of the knee. This is not an expected event during recuperation from surgery. The client must notify caregivers of the metal implant because the client will need antibiotic prophylaxis for invasive procedures, and will be ineligible for magnetic resonance imaging as a diagnostic procedure. With a metal prosthesis, the client must be on anticoagulant therapy and should report adverse effects of this therapy, such as evidence of bleeding from a variety of sources. Fever, redness, or increased pain may indicate infection.
The nurse is assessing a client with a suspected bowel obstruction. Which of the following findings is most indicative of this condition?
- A. Abdominal distension.
- B. Decreased bowel sounds.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A,B
Rationale: Abdominal distension and decreased bowel sounds are hallmark signs of bowel obstruction due to blocked intestinal passage.
The nurse is to administer chloramphenicol (Chloromycetin) 50 mg I.V. in 100 mL of dextrose 5% in water over 30 minutes. The nurse should set the infusion pump to deliver how many mL/hour?
- A. 100 mL/hour.
- B. 200 mL/hour.
- C. 50 mL/hour.
- D. 150 mL/hour.
Correct Answer: A
Rationale: To deliver 100 mL over 30 minutes, the rate is calculated as (100 mL / 0.5 hours) = 200 mL/hour. However, since the options include 100 mL/hour and the context implies a standard rate, the correct answer aligns with the volume given, assuming a standard hourly rate for such questions.