A nurse is assisting in the care of a client in the emergency department (ED). Nurses' Notes 0205: Client brought to the ED by police after being found wandering on the street.
Client able to provide identity to police but not able to identify place or time.
Family notified.
Client confused and agitated.
Appearance is disheveled.
Mucous membranes dry.
Lungs clear and equal, heart rhythm regular.
During data collection, the client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.
Vital Signs 0200: Temperature 38.6°C (101.5°F), Heart rate 104/min, Respiratory rate 18/min, Blood pressure 158/96 mm Hg, Oxygen saturation 98% on room air.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
Client confused and agitated.
Appearance is disheveled.
Mucous membranes dry
During data collection, the client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.
Temperature 38.6°C (101.5°F)
Blood pressure 158/96 mm Hg
Heart rate 104/min
Respiratory rate 18/min
Oxygen saturation 98% on room air.
The Correct Answer is ["A","B","C","D","E","F"]
The findings that require immediate follow-up are:
- Client confused and agitated: This could indicate a neurological issue or other serious condition that needs immediate attention.
- Appearance is disheveled: This could suggest neglect or other issues that need to be addressed.
- Mucous membranes dry: This could indicate dehydration which can be serious if not addressed promptly.
- Client states “Can you ask that person to leave my room?” Client is pointing to an empty chair: This could indicate hallucinations or other mental health concerns that need immediate attention.
- Temperature 38.6°C (101.5°F): This is a fever and could indicate an infection or other medical condition that needs immediate attention.
- Blood pressure 158/96 mm Hg: This is high and could indicate hypertension or other cardiovascular issues that need immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Discouraging visitation from the client’s family could increase feelings of isolation and confusion, which could exacerbate delirium.
Choice B rationale:
A high-stimulation environment could overstimulate the client and worsen delirium.
Choice C rationale:
Limiting the client’s need to make decisions can reduce stress and confusion, which can help manage delirium.
Choice D rationale:
Keeping the client’s room dark at night could disrupt the client’s sleep-wake cycle and potentially worsen delirium.
Correct Answer is B
Explanation
Choice A rationale:
It’s not appropriate to pressure the client into seeing visitors.
Choice B rationale:
It’s important to respect the client’s wishes and communicate them to the sibling.
Choice C rationale:
This could potentially cause distress for the client.
Choice D rationale:
While it might be helpful to involve the provider, the immediate issue can be addressed by the nurse.
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