A 45 year old client with a history of drug and alcohol abuse is admitted to the hospital. On day 2 the client has rapidly fluctuating moods and believes the King of England is in his room. How will the nurse document these findings?

A Overdose

B Acute dementia

C Substance abuse comorbidity

D Acute delirium

Answer and Explanation

The Correct Answer is D

Choice A Rationale: Documenting an overdose is premature without further assessment and evidence.

Choice B Rationale: Acute dementia is not typically diagnosed based on rapidly fluctuating moods alone, and it may not be appropriate for this situation.

Choice C Rationale: While substance abuse comorbidity may be present, it does not fully capture the client's current presentation.

Choice D Rationale: Documenting acute delirium is appropriate in this case. The client's symptoms, including rapidly fluctuating moods and delusions, are indicative of acute delirium, which can be related to substance withdrawal or other medical issues.

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Correct Answer is C

Explanation

Choice A Rationale: Notifying the nurse administrator should not be the first action when a client is experiencing pain or injury.

Choice B Rationale: Cleaning up the spill is important to prevent further accidents but does not address the client's immediate pain and discomfort.

Choice C Rationale: Asking the client to remain still is the best first action to ensure the client's safety and assess the extent of the injury or pain.

Choice D Rationale: Documenting the incident is important but should follow

A. A Sit the client at a 90 degree angle B. B Administer 2000 liters of fluid C. C Apply compression socks D. D Maintain blood pressure exactly at 110/80

Correct Answer is A

Explanation

Choice A Rationale: Sitting the client at a 90-degree angle (upright position) helps prevent orthostatic hypotension and cardiovascular complications in clients with spinal cord injuries by improving venous return and cardiac output.

Choice B Rationale: Administering 2000 liters of fluid is an inappropriate intervention, and the volume mentioned is excessive.

Choice C Rationale: Applying compression socks may help prevent deep vein thrombosis (DVT) but does not address cardiovascular complications related to sitting position.

Choice D Rationale: Maintaining blood pressure exactly at 110/80 is not a feasible or appropriate intervention.

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A 45 year old client with a history of drug and alcohol abuse is admitted to the hospital. On day 2 the client has rapidly fluctuating moods and believes the King of England is in his room. How will the nurse document these findings?

Nursing Test Bank

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Correct Answer is A

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