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 does not affect a client's sleep cycle."
"Delirium has a slow progression."
"Delirium has an abrupt onset."
"Delirium does not affect a client's perception of her environment."
The Correct Answer is C
Choice A rationale:
Delirium can affect a client's sleep cycle, often causing disturbances in sleep-wake patterns.
Choice B rationale:
Delirium typically has a rapid onset, not a slow progression.
Choice C rationale:
The correct statement is that delirium has an abrupt onset. Understanding this characteristic helps nurses recognize and address delirium promptly.
Choice D rationale:
Delirium can significantly impact a client's perception of the environment, leading to confusion and disorientation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Palpating the abdomen should be done cautiously and is not the first action, especially if an abdominal obstruction is suspected.
Choice B rationale:
Auscultating bowel sounds is the first action the nurse should take when assessing a client with right lower quadrant pain, nausea, and vomiting. Bowel sounds can provide information about bowel motility and potential obstruction. The nurse should use the least invasive assessment technique first, which is auscultation.
Choice C rationale:
Administering an antiemetic may be necessary, but assessing bowel sounds takes precedence in the initial assessment.
Choice D rationale:
Offering pain medication is not the first action, as the cause of the symptoms needs to be identified before pain management. Pain medication could mask the symptoms and delay diagnosis.
Correct Answer is B
Explanation
Choice A rationale:
Keeping legs crossed while sitting can contribute to venous stasis and thrombus formation and is not a recommended practice.
Choice B rationale:
Limiting the time spent sitting in a chair is a preventive measure to reduce the risk of thrombus formation.
Choice C rationale:
Performing leg exercises regularly, at least once every 1-2 hours, is beneficial in preventing thrombus formation.
Choice D rationale:
Massaging the legs when they hurt is not a primary prevention measure for thrombus formation and may not be sufficient in preventing complications.
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