A nurse is assisting in the care of a client in the intensive care unit (ICU)

Exhibits
The nurse should identify which of the following client's conditions can indicate the development of delirium.

past medical history

illusions

change in orientation

hallucinations

Answer and Explanation

Correct Answer : C,D

Rationale:

• Past medical history like Parkinson’s disease increases the risk of delirium but is not a direct symptom. It may contribute but does not confirm the presence of delirium alone. Current behavior and cognition changes are more reliable indicators.

• Illusions involve misinterpreting real stimuli, unlike this client’s perception of spiders that aren’t there. Hallucinations are a more accurate description of this experience. Therefore, illusions are less consistent with the actual findings.

• Change in orientation is a hallmark of delirium and is shown by the client’s confusion about the date and location. The sudden onset and fluctuation in awareness suggest an acute cognitive disturbance. This finding supports the development of delirium in the ICU setting.

• Hallucinations, such as seeing spiders that are not present, reflect sensory misperceptions. These are typical in hyperactive delirium and often cause agitation or fear. They indicate an altered mental state requiring urgent assessment.

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Correct Answer is A

Explanation

Rationale:

A. "The client can revoke consent even after the procedure has begun.": Clients have the legal right to withdraw consent at any time, including during a procedure. Respecting this autonomy is essential, and healthcare providers must stop the procedure if the client revokes consent.

B. "The nurse is responsible for obtaining informed consent.": Obtaining informed consent is the responsibility of the provider performing the procedure, who must ensure the client understands the risks, benefits, and alternatives. Nurses typically witness and verify the signature but do not obtain consent.

C. "Consent must be obtained from a family member if a client has a mental illness.": Consent depends on the client’s decision-making capacity, not solely on the presence of mental illness. If the client is competent, they can provide consent; if not, a legally authorized representative may be involved.

D. "The charge nurse will explain the risks of the procedure to the client.": Explaining procedure risks is the responsibility of the healthcare provider performing the procedure, not the charge nurse. This ensures that the explanation is accurate and comprehensive.

A. "I should gain half of a pound per week to meet my treatment goal’ B. "The staff will watch me closely for 1 hour after each meal’ C. "The treatment goal is to be within 60 percent of my ideal body weight." D. "The staff will weigh me every night before I go to bed."

Correct Answer is B

Explanation

Rationale:

A. "I should gain half of a pound per week to meet my treatment goal": Weight gain goals for clients with anorexia nervosa are typically more aggressive, often around 1 to 3 pounds per week, to restore healthy weight timely and prevent complications of prolonged malnutrition.

B. "The staff will watch me closely for 1 hour after each meal": Monitoring clients after meals is essential to prevent purging behaviors, such as vomiting or excessive exercise. The one-hour observation period helps ensure safety and supports recovery.

C. "The treatment goal is to be within 60 percent of my ideal body weight.": Treatment aims to restore clients to at least 85 to 90 percent of their ideal body weight to improve physical and psychological health; 60 percent is dangerously low and not an appropriate goal.

D. "The staff will weigh me every night before I go to bed.": Weighing is typically done once in the morning before breakfast and after voiding, to ensure consistency and accuracy. Nighttime weighing is not standard practice and may contribute to anxiety.

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A nurse is assisting in the care of a client in the intensive care unit (ICU) Exhibits The nurse should identify which of the following client's conditions can indicate the development of delirium.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a newly licensed nurse about informed consent. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse on a mental health unit is reinforcing teaching with a client who has anorexia nervosa. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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A nurse is assisting in the care of a client in the intensive care unit (ICU)

Exhibits
The nurse should identify which of the following client's conditions can indicate the development of delirium.