A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to Include?

"Delirium has an abrupt onset.”

"Delirium does not affect a client's perception of her environment."

"Delirium has a slow progression.”

Delirium does not affect a client's sleep cycle

Answer and Explanation

The Correct Answer is A

Delirium is an acute confusional state that develops rapidly over a short period of time, often within hours or days. It is characterized by a disturbance in consciousness and attention, along with changes in cognition and perception.

Delirium can significantly impact a client's perception of their environment. Clients with delirium may experience hallucinations, delusions, and misinterpretations of their surroundings. They may become disoriented, have difficulty recognizing familiar people or places, and exhibit altered levels of awareness and attention.

As mentioned earlier, delirium has an abrupt onset, meaning it develops rapidly. Delirium is usually a transient condition that fluctuates throughout the day, with symptoms varying in severity.

Delirium can disrupt a client's sleep-wake cycle. Clients with delirium may experience disturbances in their sleep patterns, such as difficulty falling asleep, frequent awakening during the night, or excessive sleepiness during the day.

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Correct Answer is D

Explanation

Gastric residual refers to the volume of formula or feeding remaining in the stomach after a previous feeding. A gastric residual of 300 mL is considered high and may indicate delayed gastric emptying or impaired gastrointestinal motility.

The other findings mentioned are within normal range or expected in the context of enteral feeding. A blood glucose level of 110 mg/dL is within the acceptable range. Having diarrhea once in a 24-hour period is not unusual and can be attributed to various factors. A weight gain of 0.91 kg (2 lb) in 2 days can be expected due to increased fluid intake with enteral feeding and should be monitored for further trends. However, a high gastric residual is a significant finding that warrants further assessment and intervention.

A. Remove one restraint at a time. B. Tie the restraints to the side rail, C. Secure restraints with a square knot D. Remove the restraints every 3 hr

Correct Answer is A

Explanation

When using restraints for the safety of the client and others, it is important to follow proper procedures to ensure the client's well-being and minimize the risk of injury. Removing one restraint at a time allows for better control and assessment of the client's behavior and response. It also helps maintain the client's safety by ensuring that at least one limb is restrained during the process.

Restraints should never be tied to the side rail as it can cause serious harm or injury to the client. Restraints should be attached to an immobilization device specifically designed for that purpose, such as a bed frame or a designated restraint chair.

Restraints should be secured with a quick-release mechanism, such as a buckle or Velcro, that allows for quick and easy removal in case of emergency or the need for rapid intervention. Tying restraints with a square knot can delay the removal process and may compromise the client's safety.

Restraints should only be used when necessary and as prescribed by the healthcare provider. The frequency and duration of restraint use should be based on the client's condition and the specific order from the healthcare provider. It is not appropriate to remove restraints based solely on a time schedule without considering the client's individual needs and safety. Regular assessments should be conducted to determine if continued use of restraints is required or if alternative interventions can be implemented.

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A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to Include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is A

Explanation

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