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 D
Explanation
Choice A rationale:
Documenting the fluid infusion in the client's chart is important but is not the first action to address the immediate concern.
Choice B rationale:
Reporting the incident to the unit manager can be done after taking immediate actions to address the client's well-being.
Choice C rationale:
Completing an incident report is necessary but is not the priority when the client's health is at risk.
Choice D rationale:
Obtaining the client's vital signs is the first action to assess the client's response to the inadvertent administration of a larger fluid bolus, as it helps in identifying any potential complications.
Correct Answer is D
Explanation
Choice A rationale:
A blood glucose level of 110 mg/dL is within the normal range and is an expected finding.
Choice B rationale:
A weight gain of 0.91 kg (2 lb) in 2 days could be expected in a client receiving enteral feeding due to fluid intake. However, it's important to monitor for signs of fluid overload.
Choice C rationale:
Diarrhea one time in a 24-hour period can occur in some clients but should be monitored for any patterns or changes.
Choice D rationale:
A gastric residual of 300 mL at the end of the shift is higher than expected and may indicate delayed gastric emptying or intolerance to enteral feeding. This finding should be reported.
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