A nurse is caring for a client in the intensive care unit who suddenly becomes confused and agitated. The nurse recognizes these manifestations are likely related to a condition with which of the following characteristics?
Isolated
permanent
Reversible
Unique
The Correct Answer is C
A. Isolated: This term refers to something that is separate or distinct. Confusion and agitation in a client are not typically isolated but can be part of a broader clinical picture.
B. Permanent: These manifestations are not typically permanent and can often be reversed with appropriate interventions.
C. Reversible: Confusion and agitation in a client are often reversible and can be due to various factors such as medications, infections, metabolic disturbances, or other medical conditions. Identifying and addressing the underlying cause can often restore the client to their baseline mental status.
D. Unique: While every individual's presentation may have unique aspects, confusion and agitation are not considered unique manifestations in the context of acute changes in mental status. They are common symptoms that can occur due to a variety of reasons and are not exclusive to any particular condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Third spacing: Third spacing refers to the shifting of fluid from the intravascular space into the interstitial space, leading to decreased circulating volume. While third spacing can contribute to hypovolemic shock, it is not specific to obstructive shock.
B. Cardiomyopathy: Cardiomyopathy is a condition characterized by abnormalities in the heart muscle structure and function. While cardiomyopathy can lead to heart failure, it is not directly associated with obstructive shock.
C. Cardiac tamponade: Cardiac tamponade occurs when fluid accumulates in the pericardial sac, compressing the heart and impairing its ability to fill properly. This condition can lead to obstructive shock due to decreased cardiac output. Signs and symptoms include hypotension, muffled heart sounds, distended neck veins, and pulsus paradoxus.
D. Ruptured aneurysm: A ruptured aneurysm can lead to hypovolemic shock due to acute blood loss. While it can cause significant hemodynamic instability, it is not a characteristic diagnosis of obstructive shock.
Correct Answer is C
Explanation
A) "Vision changes occur when pressure in the eye is increased due to a decrease of aqueous humor." This statement describes a mechanism associated with glaucoma, not cataracts. In cataracts, vision changes occur due to the opacity or cloudiness of the lens, not changes in intraocular pressure.
B) "Vision changes occur when blood vessels leak fluid or blood under a portion of the retina." This statement describes a mechanism associated with retinal diseases like diabetic retinopathy, not cataracts. In cataracts, the lens becomes cloudy, affecting the passage of light through the eye.
C) "Vision changes occur when the cloudy lens alters the passage of light through the eye." This statement is correct. Cataracts cause the lens of the eye to become cloudy, which interferes with the passage of light through the eye. This results in vision changes such as blurred vision, glare, and difficulty seeing in low light conditions.
D) "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye." This statement describes a mechanism associated with retinal detachment, not cataracts. In cataracts, the lens becomes opaque, but the retinal tissue remains intact.
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