A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect?
Hallucinations
Аgnosia
Bradycardia
Aphasia
The Correct Answer is A
A. Hallucinations: Hallucinations are common in clients experiencing delirium, especially when it is related to a febrile or acute medical illness. They can involve seeing or hearing things that are not present and reflect the acute cognitive disturbances characteristic of delirium.
B. Agnosia: Agnosia is the inability to recognize familiar objects, people, or sounds and is more commonly associated with neurodegenerative disorders such as dementia rather than acute delirium. It is not a typical finding in febrile-induced delirium.
C. Bradycardia: Delirium related to a febrile illness usually does not cause bradycardia. Vital signs are more likely to show tachycardia due to fever or systemic infection. Bradycardia would suggest a different cardiac or medication-related issue.
D. Aphasia: Aphasia, the impairment of language expression or comprehension, is generally linked to stroke or localized brain injury. It is not a common manifestation of acute delirium caused by a febrile illness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Limit each of the client's visitors to 1 hr per day: Visitor restrictions for clients with sealed radiation implants typically focus on limiting cumulative exposure to radiation rather than a strict daily time limit. The exact duration may vary, but monitoring personal exposure is more critical for staff safety.
B. Remove dirty linens from the room after double bagging: For sealed radiation implants, the radioactive source remains contained, and linens are not highly radioactive. Standard precautions are sufficient, so special double-bagging is not required unless the linens are contaminated with bodily fluids.
C. Wear a dosimeter film badge while in the client's room: Staff who care for clients with sealed radiation implants must wear a dosimeter to monitor cumulative radiation exposure. This ensures that occupational safety limits are not exceeded and provides documentation of exposure levels, which is a key safety measure in the plan of care.
D. Ensure family members remain at least 1 m (3.2 feet) from the client: Family members may need limited exposure, but strict distance alone is not sufficient for safety or required for all types of sealed implants. Staff exposure monitoring via dosimeter is more critical, as they spend more time in the room and are at greater risk for cumulative exposure.
Correct Answer is A
Explanation
A. "My baby should have at least three bowel movements per day after 4 days of age.": This statement reflects correct understanding. By the fourth day of life, a healthy, breastfed newborn typically passes at least three yellow, seedy stools per day, indicating adequate intake and gastrointestinal function.
B. "I should expect my baby to make a grunting sound when breathing": Grunting is a sign of respiratory distress in a newborn and is not expected in a healthy infant. The client should be taught to report any abnormal respiratory sounds immediately.
C. "I should put my baby on a feeding schedule.": Newborns should feed on demand rather than on a strict schedule to ensure adequate nutrition and support breastfeeding. Rigid scheduling can lead to insufficient intake and dehydration.
D. "My baby should sleep for at least 4 hours between feedings during the night.": Newborns typically need to feed every 2–3 hours, including at night. Expecting the infant to sleep for 4 hours between feeds may indicate misunderstanding of normal feeding patterns and could result in inadequate caloric intake.
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