A family member brought a senior to the clinic. The family member explained to the nurse that the patient suddenly from one day to the other, started with confusion, and agitation. The family states the patient used to be orientated and with very calm behavior. The nurse suspects that this patient is experiencing:

Delirium

Sundowning

Alzheimers

Dementia

Answer and Explanation

The Correct Answer is A

A. Delirium: Delirium is characterized by a sudden onset of confusion, agitation, and fluctuating levels of consciousness. It often develops over a short period, such as hours to days, and is typically associated with an underlying medical condition, medication, or infection. The patient's rapid change from being oriented and calm to confused and agitated suggests a sudden onset, which is indicative of delirium.
B. Sundowning: Sundowning refers to a pattern of increased confusion and agitation that occurs in the late afternoon or evening, primarily in individuals with dementia. While it involves fluctuations in mental status, it does not usually present with a sudden onset of symptoms as described in this case.
C. Alzheimer’s: Alzheimer’s disease is a form of chronic dementia characterized by gradual and progressive cognitive decline over months to years. The sudden onset of confusion and agitation does not align with the gradual progression typical of Alzheimer's disease.
D. Dementia: Dementia is a general term for a decline in cognitive ability that affects daily life, usually developing gradually over time. Unlike delirium, dementia does not present with a sudden change in behavior or mental status, making it less likely in this scenario where the change was abrupt.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Assist the client to a standing position: While positioning can be important for various assessments, inspecting the apical impulse is best done with the client in a supine or left lateral position. Standing may not provide the best view or palpation for the apical impulse, which is usually assessed more accurately in a different position.

B. Focus a penlight on the client's chest: A penlight alone may not provide sufficient illumination for detailed inspection of the apical impulse. It is more important to use appropriate lighting techniques to ensure a clear view of the heart's movements.

C. Use tangential lighting: Tangential lighting is particularly useful for inspecting and palpating the apical impulse because it casts light across the surface, highlighting contours and movements. This type of lighting helps the nurse visualize the apical impulse more clearly by creating shadows that accentuate the impulse's presence and movements.

D. Use perpendicular lighting: Perpendicular lighting might not be as effective in highlighting the subtle movements of the apical impulse. Tangential lighting is preferred because it creates shadows and contrasts that make the apical impulse more visible and easier to assess.

A. BMI of 20 B. Peripheral neuropathy C. Immobility D. Hypoperfusion

Correct Answer is ["B","C","D"]

Explanation

A. BMI of 20: While a BMI of 20 is on the lower end of the normal range, it does not necessarily indicate a high risk for pressure injuries. Extreme low BMI may pose a risk, but a BMI of 20 alone is not a definitive factor in increasing pressure injury risk compared to the other listed conditions.
B. Peripheral neuropathy: Peripheral neuropathy impairs sensation in the skin, which reduces the client’s ability to feel pressure, pain, or discomfort. This diminished sensory perception increases the risk of developing pressure injuries as the client might not be aware of or respond to pressure-related issues.
C. Immobility: Immobility, or limited mobility, significantly raises the risk of pressure injuries because it prevents the client from frequently changing positions. Prolonged pressure on specific body areas can impede blood flow and lead to skin breakdown.
D. Hypoperfusion: Hypoperfusion indicates reduced blood flow to tissues, which can contribute to tissue ischemia and increase the risk of pressure injuries. Inadequate blood flow prevents adequate oxygen and nutrient delivery to the skin, making it more susceptible to damage.

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Naxlex Comprehensive Predictor Exams

The nurse is planning to inspect a client's apical heart impulses. What should the nurse do to ensure an accurate assessment of this organ?

Correct Answer is C

Explanation

A nurse is performing a pressure injury risk assessment for a client. Which of the following findings increases the client's risk of a pressure injury?

Correct Answer is ["B","C","D"]

Explanation

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