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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Correct Answer is D

Explanation

A) The tricuspid area: The tricuspid area is located at the lower left sternal border, around the 4th or 5th intercostal space. It is where the tricuspid valve sounds are best heard, not the area for auscultating the 2nd rib space.
B) Erb's point: Erb's point is located at the left sternal border in the 3rd intercostal space. It is a key area for auscultating both the aortic and pulmonic valves, as well as the mitral and tricuspid valves, but it is not associated with the right 2nd rib space.
C) The mitral area: The mitral area, also known as the mitral valve area, is located at the 5th intercostal space at the midclavicular line on the left side. This area is used for auscultating the mitral valve, not the right 2nd rib space.
D) The aortic area: The right 2nd rib space, also known as the 2nd intercostal space at the right sternal border, is the location where the aortic valve sounds are best auscultated. This area is used to listen to the aortic valve's closure and is the first location for cardiac auscultation.

A. Peripheral Pulses B. Skin temperature C. Pitting Edema D. Capillary refill

Correct Answer is C

Explanation

Rationale:
A) Peripheral Pulses: Peripheral pulses are assessed by palpating the pulse points, such as the radial or dorsalis pedis pulse, to evaluate the strength and regularity of the pulse. This assessment is not related to pressing the skin and observing it for indentation.
B) Skin Temperature: Skin temperature is assessed by palpating the skin with the back of the hand or fingers to detect warmth or coolness. This method does not involve pressing with the thumb and assessing for indentation.
C) Pitting Edema: Pitting edema is assessed by applying pressure to the skin over a bony area, such as the tibia or ankle, and then observing the skin's response after releasing the pressure. The presence of a pit or indentation that remains after the pressure is removed indicates pitting edema, which is a sign of fluid retention.
D) Capillary Refill: Capillary refill is assessed by pressing down on the nail bed or the skin and then observing how quickly the color returns after releasing the pressure. This test measures peripheral circulation and is different from the assessment for pitting edema.

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Naxlex Comprehensive Predictor Exams

The right 2nd rib space is the first location for cardiac auscultation and is also known as:

Correct Answer is D

Explanation

While performing an assessment the nurse presses the client's arm with the tip of her thumb, holds for a few seconds and releases. The nurse observes the client as shown. What is the nurse assessing?

Correct Answer is C

Explanation

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