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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 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.

A. Suppression B. Reaction formation. C. Splitting. D. Projection.

Correct Answer is A

Explanation

Choice A rationale:

Suppression is a conscious decision to delay paying attention to an emotion or need in order to cope with the present reality. In this case, the client is choosing to delay thinking about their health until after their son’s wedding.

Choice B rationale:

Reaction formation is behaving in a way that is exactly the opposite of one’s true feelings. This is not evident in the client’s statement.

Choice C rationale:

Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. This is not evident in the client’s statement.

Choice D rationale:

Projection is attributing one’s unacceptable thoughts and feelings onto another who does not have them. This is not evident in the client’s statement.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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 caring for a client who has a new diagnosis of cancer. The client states, "I can't think about my health until after my son is married next week.”. The nurse should identify the client's statement as an indication of which of the following maladaptive defense mechanisms?.

Correct Answer is A

Explanation

A nurse is reinforcing teaching about a new prescription for haloperidol with a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching?.

A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?.

A nurse is contributing to the plan of care for a client who has acute delirium. Which of the following interventions should the nurse include in the plan of care? .

A nurse is collecting data from a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply.) .

A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.) .

A nurse is collecting data from an adult client in an outpatient mental health clinic. The nurse should identify which of the following events as a potential cause of a maturational crisis?.

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 providing information to a client about smoking cessation. Which of the following medications should the nurse include?.