A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?
Ineffective community coping.
B Disturbed sensory perception.
Self-care deficit.
Acute confusion.
The Correct Answer is D
A. Ineffective community coping may be a concern for a homeless individual but is not the priority in this scenario where the client is disoriented and confused.
B. Disturbed sensory perception typically involves alterations in visual, auditory, tactile, or olfactory senses, which may not be the primary issue in this case.
C. While self-care deficit could be a concern for a homeless individual, it is not the priority when the client is disoriented, disorganized, and confused.
D. Acute confusion is the priority problem because the client is disoriented, disorganized, and confused, indicating a cognitive impairment that needs immediate attention. E. There is no specific rationale provided for this option.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. MAO inhibitors such as phenelzine can cause significant fluctuations in blood pressure, including hypertensive crisis when combined with certain foods or medications. Therefore, monitoring blood pressure is crucial to detect and prevent hypertensive emergencies.
B. While monitoring urinary output is important for overall assessment, it is not specifically associated with the use of MAO inhibitors like phenelzine.
C. Respiratory rate is not typically affected by MAO inhibitors like phenelzine and may not be the most relevant assessment finding in this scenario.
D. Temperature monitoring is important for general assessment but is not specifically associated with the use of MAO inhibitors like phenelzine.
Correct Answer is A
Explanation
A. Caring for an older parent and her own children simultaneously can lead to significant caregiver role strain due to the increased responsibilities and demands on the client's time and energy.
B. Feeling anxious to leave for personal appointments may indicate stress but does not specifically address caregiver role strain.
C. Taking naps in her car during lunch hour may suggest fatigue or exhaustion but does not directly relate to caregiver role strain.
D. Working an average of 60 hours per week may contribute to overall stress and fatigue but does not specifically address the client's role as a caregiver for her parent and children.
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