A client voluntarily admitted to the inpatient psychiatric unit is currently experiencing mild delirium. The client approaches the nurse and states, "I’m going to take a walk outside. I'll be back in about 10 minutes." Which is the most appropriate nursing action?
Designate a staff member to accompany the client on the walk
Tell the client the walk is not allowed and restrict him to the unit
Further assess the client's motives for wanting to walk
Give the client permission to go on a walk on the grounds
The Correct Answer is A
Choice A reason: Mild delirium involves acute confusion and impaired judgment due to cerebral dysfunction, often from metabolic or infectious causes. Accompanying the client ensures safety, as disorientation increases wandering or injury risk. Supervision mitigates risks from altered cognition while allowing mobility, supporting cerebral recovery without exacerbating confusion.
Choice B reason: Restricting the client to the unit may increase agitation, as delirium’s neurochemical imbalances, like acetylcholine deficiency, heighten restlessness. While safety is critical, blanket restriction ignores the potential benefits of supervised movement, which can reduce stress and improve cerebral perfusion, making this less appropriate than supervised accompaniment.
Choice C reason: Assessing motives may clarify intent but delays addressing immediate safety in delirium, where confusion stems from cerebral dysfunction, such as hypoxia or electrolyte imbalance. The client’s impaired judgment requires supervision over exploration of motives, as disorientation increases risk of harm, making this a secondary action.
Choice D reason: Allowing an unsupervised walk is unsafe in delirium, as acute cognitive impairment from neurotransmitter imbalances or metabolic disturbances increases wandering or injury risk. Without supervision, the client may become disoriented or lost, exacerbating cerebral stress. Accompanied walks better balance safety and mobility in this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Derealization, a dissociative symptom in PTSD, involves feeling detached from reality, linked to altered prefrontal cortex and limbic system activity. Panic from a similar ICU case suggests a triggered memory, not detachment. Derealization is less likely, as the nurse’s response aligns with reliving a traumatic event, not perceptual distortion.
Choice B reason: Hyperarousal in PTSD involves heightened alertness and exaggerated startle, driven by amygdala hyperactivity and elevated norepinephrine. While panic suggests arousal, the trigger of a similar ICU case points to reliving a specific traumatic memory, making flashback more precise than general hyperarousal, which lacks the event-specific re-experiencing component.
Choice C reason: A flashback in PTSD involves reliving a traumatic event, triggered by cues like a similar ICU case, due to amygdala-driven memory reactivation and hippocampal dysfunction. The nurse’s panic reflects re-experiencing the parent’s death, a hallmark of PTSD, where sensory cues vividly recall trauma, causing intense emotional distress.
Choice D reason: Emotional numbing in PTSD involves reduced emotional responsiveness, linked to prefrontal cortex suppression. Panic from a similar ICU case indicates an active emotional response, not numbing. The nurse’s reaction aligns with re-experiencing trauma via a flashback, driven by amygdala activation, rather than emotional detachment.
Correct Answer is C
Explanation
Choice A reason: Administering 2 teaspoons (10 mL) would deliver 500 mg of Amoxicillin, as the concentration is 250 mg/5 mL, and 1 teaspoon equals 5 mL. This dose is double the prescribed 250 mg, risking overdose. Amoxicillin overdose can cause gastrointestinal distress or, in rare cases, renal toxicity, making this choice scientifically inappropriate for the prescribed dose.
Choice B reason: Giving 3 teaspoons (15 mL) would deliver 750 mg of Amoxicillin, far exceeding the prescribed 250 mg dose. The concentration is 250 mg/5 mL, so 15 mL contains three times the required amount. This could lead to adverse effects like diarrhea or allergic reactions, as excessive antibiotic levels disrupt gut flora and increase toxicity risks.
Choice C reason: One teaspoon (5 mL) delivers exactly 250 mg of Amoxicillin, matching the prescribed dose, as the concentration is 250 mg/5 mL. This ensures therapeutic efficacy for treating infections like otitis media in children, maintaining serum levels within the therapeutic range (MIC for common pathogens like Streptococcus pneumoniae), minimizing side effects, and adhering to pediatric dosing guidelines.
Choice D reason: Four teaspoons (20 mL) would deliver 1000 mg of Amoxicillin, four times the prescribed dose. At 250 mg/5 mL, this excessive dose risks severe side effects, including nephrotoxicity or hepatotoxicity, and disrupts microbial balance, potentially causing antibiotic resistance. This is scientifically inappropriate, as it deviates significantly from the therapeutic dose for an 8-year-old.
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