A nurse is assisting in the care of a client in the intensive care unit (ICU).
Drag words from the choices below to fill in each blank in the following sentence.
The nurse should identify that the client's
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Delirium is an acute, fluctuating disturbance in attention and cognition commonly triggered by infection, hypotension, hypoxia, or systemic inflammation. In this case, the client has sepsis likely from a surgical site infection, evidenced by fever, hypotension, elevated WBC count, and wound drainage. Neurologic changes such as fluctuating orientation and perceptual disturbances are key indicators of delirium and require immediate identification to prevent injury and worsening clinical decline.
Rationale for correct choices:
• Change in orientation: An acute change in orientation, such as confusion about time, place, or situation, is one of the earliest and most reliable indicators of delirium. The client initially was oriented but later becomes disoriented to time (“It’s 1975”) and only partially oriented to person and place. This fluctuating cognitive status reflects acute brain dysfunction rather than a chronic condition like dementia. Such changes are often caused by systemic infection, hypoperfusion, or metabolic disturbances and require urgent intervention.
• Hallucinations: Hallucinations, such as the client reporting spiders crawling on the bed, are a hallmark of severe delirium. These false sensory perceptions occur due to acute brain dysfunction affecting perception and reality testing. In this case, the visual and tactile hallucinations indicate worsening neurocognitive impairment likely driven by sepsis and hypotension. Hallucinations significantly increase risk for agitation, unsafe behaviors, and self-harm, requiring immediate safety interventions and medical evaluation.
Rationale for incorrect choices:
• Illusions: Illusions are misinterpretations of real external stimuli rather than perceiving something that is not present. While delirious clients can experience illusions, the scenario specifically describes hallucinations (seeing and feeling spiders with no external stimulus). Therefore, illusions do not best fit the described symptoms. The client’s presentation reflects more severe perceptual disturbance consistent with hallucinations rather than simple misinterpretation.
• Past medical history: Although the client has significant past medical conditions such as Parkinson’s disease and heart failure, these do not directly indicate the development of delirium. Past medical history may increase vulnerability but is not a clinical sign of acute cognitive change. Delirium is diagnosed based on current acute changes in mental status, not historical health information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Delegation in nursing involves assigning appropriate tasks to assistive personnel while maintaining accountability for patient outcomes. When an assistive personnel refuses an assignment, the nurse must assess the reason for refusal before taking corrective or punitive action. Effective delegation requires communication, clarification of expectations, and evaluation of competency or safety concerns. The goal is to ensure patient safety while maintaining a functional and collaborative team environment.
Rationale:
A. Reporting the AP to the risk manager is inappropriate as an immediate response because refusal may be due to legitimate concerns such as lack of training or unsafe assignment. Risk management involvement is reserved for unresolved or repeated issues after assessment and communication. Immediate escalation without understanding the cause does not support effective problem-solving.
B. Assigning the task to another AP may resolve the immediate workload issue but does not address the underlying reason for refusal. This approach may perpetuate unsafe practice if the task is inappropriate for assistive personnel or if multiple staff have similar concerns. Proper delegation requires evaluating appropriateness rather than simply reassigning tasks.
C. Performing the task on behalf of the AP is not appropriate as a routine response because it undermines delegation principles and may lead to nurse workload imbalance. While patient safety is always a priority, the nurse should first determine why the task was refused. Direct replacement should only occur if the task is urgent and cannot be safely delegated.
D. Discussing the AP’s concerns is the correct first action because it allows the nurse to identify whether the refusal is based on lack of competency, misunderstanding, workload issues, or safety concerns. In effective delegation systems, communication is essential to ensure tasks are appropriate and safely assigned. This aligns with principles of delegation and teamwork in nursing practice, including safe delegation to Assistive personnel.
Correct Answer is A
Explanation
Sleep disturbances in preschool-aged children are commonly related to inconsistent routines, overstimulation, and poor sleep hygiene. At this developmental stage, establishing predictable bedtime habits is essential for promoting healthy sleep patterns and emotional regulation. Exposure to stimulating activities such as screens can delay sleep onset by increasing arousal and suppressing melatonin secretion. Nurses should educate caregivers on structured routines that support restful sleep in children during early development.
Rationale:
A. Limiting media use before bedtime is appropriate because screen exposure increases cognitive stimulation and delays sleep onset. Blue light from devices can suppress melatonin production, disrupting the child’s natural sleep-wake cycle. Reducing screen time before bed promotes relaxation and improves sleep quality in preschool children.
B. Allowing the child to stay up later is not recommended because it disrupts circadian rhythm and can worsen sleep disturbances. Preschool children require consistent sleep schedules to support growth, behavior regulation, and cognitive development. Delayed bedtime often leads to overtiredness and more difficulty falling asleep.
C. Altering bedtime rituals daily is inappropriate because inconsistent routines increase anxiety and reduce the child’s ability to anticipate sleep. Predictable bedtime routines provide security and signal the transition from wakefulness to sleep. Frequent changes can exacerbate sleep resistance and disturbances.
D. Avoiding a night light is not necessary and may actually increase fear or nighttime anxiety in some preschool children. A low-intensity night light can provide reassurance and help reduce sleep disruptions related to fear of darkness. The key is moderation rather than complete elimination.
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