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 sleep cycle."
"Delirium has a slow progression."
"Delirium does not affect a client's perception of her environment."
The Correct Answer is A
Choice A reason:
Delirium is a sudden and acute change in mental status characterized by confusion, disorientation, altered consciousness, and other cognitive disturbances. It has an abrupt onset and is often related to an underlying medical condition, medication, or other factors such as infections or metabolic imbalances.
Choice B reason:
Delirium can indeed affect a client's sleep cycle. It often disrupts sleep patterns and can lead to sleep disturbances
Choice C reason:
Delirium does not have a slow progression. It is typically characterized by a rapid and fluctuating course, and it can develop over hours to days.
Choice D reason:
Delirium does affect a client's perception of their environment. Clients with delirium may experience hallucinations, paranoia, and other alterations in perception. They may be unable to accurately interpret or interact with their surroundings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Obtaining printed information about insulin self-administration is a first recommendation as it can be done after ensuring the client's ability to afford the supplies.
Choice B reason:
Making a copy of the medication reconciliation form for the client is not a first recommendation as it can be done after ensuring the client's access to supplies.
Choice C reason:
Determining whether the client can afford the insulin administration supplies is the first action to be taken. The first step should be to ensure that the client can afford the insulin administration supplies. Proper management of diabetes requires having access to the necessary equipment, including insulin, syringes, pens, or other devices. If the client cannot afford these supplies, alternative options or assistance programs may need to be explored to ensure the client's safety and well-being.
Choice D reason:
Providing the client with the contact number for a diabetes education specialist is important for long-term management, but addressing the affordability of supplies should take precedence initially.
Correct Answer is A
Explanation
Choice A reason:
A. Dilated pupils
During the alarm reaction stage of the general adaptation syndrome (GAS), the body's initial response to stress triggers the "fight or flight" response. This response is characterized by the release of stress hormones, increased sympathetic nervous system activity, and various physiological changes to prepare the body to respond to the stressor. Dilated pupils are one of the manifestations of the fight or flight response, allowing for improved visual acuity and awareness of the environment.
Choice B reason:
Physical exhaustion is inappropriate. This is typically associated with the exhaustion stage of GAS, which follows the alarm reaction stage.
Choice C reason:
Bradycardia is inappropriate. Bradycardia (slow heart rate) is not a typical manifestation during the alarm reaction stage. Increased heart rate (tachycardia) is more common during this stage.
Choice D reason:
Depression is inappropriate. Depression is not a direct manifestation of the alarm reaction stage. It is a psychological response that may occur during or after prolonged stress and may be associated with the later stages of GAS.
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