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
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
The Correct Answer is ["A","B","C","D","E","F","G"]
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 A
Explanation
Choice A rationale:
A timeout is a de-escalation technique where the client is allowed to spend time alone in a safe environment to regain control.
Choice B rationale:
Restraint is not a de-escalation technique. It is a last resort measure used when other methods have failed and the client is a danger to themselves or others.
Choice C rationale:
Diversion is a technique used to distract the client from a stressful situation, not a de-escalation technique.
Choice D rationale:
A therapeutic hold is a type of physical restraint, not a de-escalation technique.
Correct Answer is B
Explanation
Choice A rationale:
A consistent state of depression is not indicative of delirium, but rather a mood disorder.
Choice B rationale:
Fluctuating levels of orientation are a hallmark sign of delirium and should be reported to the provider.
Choice C rationale:
Obsessive behaviors are not typically associated with delirium, but may be indicative of an anxiety disorder.
Choice D rationale:
Gradual memory loss is more indicative of dementia, not delirium, which is typically a sudden onset.
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