A nurse is caring for a client who has delirium. Which of the following findings should the nurse expect?

Gradual onset

Impaired judgment

Difficulty swallowing

Slowed, flat speech

Answer and Explanation

The Correct Answer is B

Choice A reason: Delirium is characterized by an acute onset, typically developing over hours to a few days. It is a sudden change in mental status that differs from conditions like dementia, which have a gradual onset. Therefore, gradual onset is not a characteristic finding of delirium.

Choice B reason: Impaired judgment is a common finding in delirium. Clients with delirium often have fluctuating levels of consciousness, attention deficits, and disorganized thinking, all of which can contribute to poor judgment. This cognitive impairment can lead to unsafe behaviors and difficulty in making decisions.

Choice C reason: Difficulty swallowing, or dysphagia, is not typically associated with delirium. Dysphagia is more often related to neurological conditions such as stroke, Parkinson's disease, or other disorders affecting the muscles involved in swallowing. While clients with delirium may have various physical symptoms due to underlying causes, difficulty swallowing is not a direct symptom of delirium itself.

Choice D reason: Slowed, flat speech is not a typical finding in delirium. Clients with delirium may exhibit rapid, incoherent, or disorganized speech due to their altered mental state. Slowed, flat speech is more commonly seen in conditions like depression or certain types of dementia rather than in acute delirium.

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Correct Answer is C

Explanation

Choice A reason: While a stimulating environment can be beneficial in engaging a client with Alzheimer's disease, it is not directly related to assisting with activities of daily living (ADLs). The goal is to create an environment that simplifies tasks and reduces confusion, which might be better achieved through other methods.

Choice B reason: Offering several choices for daily activities and meals can overwhelm a client with Alzheimer's disease. Simplifying choices and providing clear, structured routines are more effective strategies. Too many options can lead to confusion and difficulty in decision-making for these clients.

Choice C reason: Providing clothing with elastic or fastening tape simplifies the process of dressing and undressing, making it easier for the client to maintain independence in ADLs. This type of clothing can reduce frustration and promote a sense of autonomy, which is crucial for clients with Alzheimer's disease.

Choice D reason: Keeping the bedroom dark while the client is sleeping can promote better sleep, but it does not directly assist with performing ADLs. Ensuring the client has adequate lighting and a safe environment during waking hours is more relevant to supporting their ability to perform daily activities.

A. You might have extreme fatigue for several weeks after the device is implanted. B. Your voice might sound hoarse after the device is implanted. C. Your depression will improve within 72 hours after the device is implanted. D. You can schedule an appointment with your provider to turn the device off.

Correct Answer is B

Explanation

Choice A reason: Extreme fatigue for several weeks is not a common side effect associated with the implantation of a vagus nerve stimulator. While patients may experience some discomfort and mild fatigue immediately following surgery, it is typically short-term. Prolonged extreme fatigue is not a standard outcome and would warrant further medical evaluation if it occurs.

Choice B reason: Hoarseness or changes in voice is a common side effect after the implantation of a vagus nerve stimulator. The stimulator affects the vagus nerve, which is close to the vocal cords. As a result, stimulation can lead to changes in voice, including hoarseness. Patients should be informed of this potential side effect so they are not alarmed if it occurs.

Choice C reason: It is unrealistic to expect depression to improve within 72 hours after the implantation of a vagus nerve stimulator. While this treatment can be effective for certain individuals with treatment-resistant depression, it generally takes several weeks to months for patients to notice significant improvement in their symptoms. Setting realistic expectations is crucial for patient adherence and satisfaction with the treatment.

Choice D reason: Patients should not assume they can schedule an appointment at any time to turn off the device. The vagus nerve stimulator is implanted as part of a treatment plan, and any changes to its operation should be thoroughly discussed with and managed by the healthcare provider. Turning off the device without proper consultation can impact the effectiveness of the treatment and the patient’s overall health.

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A nurse is caring for a client who has delirium. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who has Alzheimer's disease. Which of the following actions should the nurse recommend implementing to assist the client with performing ADLs?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who is scheduled for implantation of a vagus nerve stimulator. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client about naltrexone. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is contributing to the plan of care for a client who has schizophrenia. The client often directs brief, hostile verbal outbursts toward the staff. Which of the following interventions should the nurse recommend?

A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for buspirone. Which of the following information should the nurse include?

A nurse is reinforcing teaching about home care with the family of a client who has Alzheimer's disease and wanders at night. Which of the following instructions should the nurse include?

A nurse is preparing to discharge a client who has depression. Which of the following information should the nurse plan to reinforce with the client regarding relapse?

A nurse is collecting data from a client who reports cessation of nicotine use. Which of the following manifestations should the nurse expect? (Select all that apply.)

A nurse in a pediatric clinic is caring for a school-age child who has a perforated eardrum. The nurse suspects abuse. Which of the following actions should the nurse take?

A charge nurse overhears a staff nurse talking to a nurse from another unit in the hallway. The staff nurse says, "I heard that Mr. Smith was admitted for a suicide attempt." Which of the following responses should the charge nurse make?