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.

Answer and Explanation

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.

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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.

A. Cardiac arrhythmia B. Crohn's disease. C. Renal colic. D. Asthma.

Correct Answer is A

Explanation

Choice A rationale:

Cardiac arrhythmia is a contraindication for electroconvulsive therapy (ECT) because ECT can cause changes in heart rate and blood pressure, which could be dangerous for someone with an existing heart condition.

Choice B rationale:

Crohn’s disease is not a contraindication for ECT. It is a chronic inflammatory bowel disease, and while it can cause significant health problems, it does not directly affect the safety or efficacy of ECT.

Choice C rationale:

Renal colic, a type of pain that can occur when a kidney stone is present, is not a contraindication for ECT. It is unrelated to the brain and nervous system and does not affect the safety or efficacy of ECT.

Choice D rationale:

Asthma is not a contraindication for ECT. While severe asthma should be well-controlled before any procedure that involves anesthesia, it is not a direct contraindication for ECT.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium? .

Correct Answer is B

Explanation

A nurse is reviewing the medical record of a client who is to receive electroconvulsive therapy. The nurse should notify the provider for which of the following findings?.

Correct Answer is A

Explanation

A nurse is reinforcing behavior management techniques with the parent of a school-age child who has conduct disorder. Which of the following statements by the parent indicates an understanding of the redirection technique? .

A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?.

A nurse is preparing to administer sertraline 50 mg PO once daily to a client who has depressive disorder. Available is sertraline oral solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.).

A nurse is reinforcing teaching with a newly licensed nurse about the Patient Self-Determination Act (PSDA). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?.

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder. Which of the following actions should the nurse take first? .

A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?.

A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse, "This baby constantly cries. My partner works all the time, and I can't take any more.”. Which of the following responses is the nurse's priority?.

A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?.