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A nurse is caring for a client who experienced a fall.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client's progress.

Answer and Explanation

The Correct Answer is []

Condition Most Likely Experiencing:

Delirium

The client's acute confusion, restlessness, disorientation, and inability to perform basic tasks suggest delirium rather than dementia or normal aging. Delirium often has an underlying cause, such as infection or medication side effects, and requires immediate intervention.

Actions to Take:

Monitor for an underlying infection.

Explanation: Infections, particularly urinary tract infections (UTIs) in older adults, are a common cause of delirium. Since the client has been incontinent, an infection could be contributing to the confusion. Identifying and treating the infection can help resolve symptoms.

Use symbols rather than written signs for directions.

Explanation: Since the client is confused and struggling to recognize basic instructions (e.g., confusing the call light with the TV remote), visual cues like symbols can help them navigate their environment and follow instructions more easily.

Parameters to Monitor:

Presence of agnosia.

Explanation: Agnosia (difficulty recognizing objects or their use) can indicate cognitive decline. The client mistaking a washcloth for something that belongs in a dryer suggests possible cognitive impairment, and tracking this symptom will help assess changes in mental status.

Ability to complete familiar tasks.

Explanation: Monitoring whether the client can complete daily activities (e.g., using the call light correctly, self-care) will help determine if their confusion is improving or worsening over time.

Incorrect Choices and Explanations:

Anticipate a prescription for donepezil.

Why Incorrect? Donepezil is used for Alzheimer’s disease, which develops gradually, unlike delirium, which is sudden and reversible if the cause is treated.

Anticipate a prescription for duloxetine.

Why Incorrect? Duloxetine is an antidepressant. While depression can cause confusion, this case strongly suggests acute delirium rather than major depressive disorder.

Determine the date of the client’s last eye examination.

Why Incorrect? Vision problems are not the primary concern in this case. The client's confusion is more likely related to delirium rather than visual impairment.

Night vision.

Why Incorrect? While vision problems can impact safety, the client’s confusion is the main issue here, not their ability to see at night.

Attendance at group therapy.

Why Incorrect? Group therapy is useful for conditions like depression or dementia but does not address the immediate, acute nature of delirium.

Oxygen saturation.

Why Incorrect? The client’s oxygen saturation is already normal (97%), making it an unlikely cause of the delirium. The focus should be on potential infection or other triggers.

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Correct Answer is C

Explanation

Choice A rationale:

Restricting interactions with other clients may be necessary in some cases, but it’s not the first precaution to take. The nurse must first ensure the client’s safety.

Choice B rationale:

Documenting the client’s behavior every 2 hr is important, but it’s not the first precaution. The nurse must first ensure the client’s safety.

Choice C rationale:

Implementing 24-hr one-to-one nursing observation is the first precaution the nurse should take. This ensures the client’s safety following an overdose.

Choice D rationale:

Administering prescribed medication via the IM route is not a precaution. It’s a method of medication administration.

A. "I should re-engage my child in an appropriate activity.”. B. "I should move closer to my child when they are agitated.”. . C. "I should use role-playing to enhance new behavioral skills.”. . D. "I should ignore attention-seeking behaviors.”. . .

Correct Answer is A

Explanation

Choice A rationale:

Re-engaging the child in an appropriate activity is a good example of the redirection technique.

Choice B rationale:

Moving closer to the child when they are agitated could escalate the situation rather than calm it.

Choice C rationale:

Using role-playing to enhance new behavioral skills is a good strategy, but it is not an example of the redirection technique.

Choice D rationale:

Ignoring attention-seeking behaviors could lead to an escalation of those behaviors as the child seeks attention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication. The client has prescriptions for an anxiolytic and an SSRI antidepressant. Which of the following precautions should the nurse take?.

Correct Answer is C

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? .

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has bipolar disorder and has a new prescription for lithium. To address possible adverse effects, the nurse should include that which of the following laboratory values will be monitored while the client is taking this medication? .

A nurse is caring for a client who is receiving acute care for the treatment of a substance use disorder. With which of the following actions is the nurse demonstrating the ethical principle of veracity?.

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 the caregiver of a client who has Alzheimer's disease. The caregiver reports that the client awakens at night and wanders. Which of the following strategies should the nurse suggest?.

A nurse is collecting data for a health history from a client who has antisocial personality disorder. Which of the following clinical findings is associated with this disorder?.

A nurse is caring for multiple clients on a mental health unit. Which of the following clients should the nurse attend to first?.

A nurse is contributing to the plan of care for a client who has bipolar disorder and whose admission was voluntary. For which of the following interventions should the nurse confirm that the client has given informed consent?.

A nurse is collecting data from a client who has schizophrenia. Which of the following client statements indicates that the client is experiencing a command hallucination? .