A nurse is caring for an elderly client diagnosed with a urinary tract infection (UTI). The family reports an abrupt onset of altered mental status, disorientation, and intermittent hallucinations. The nurse would identify these signs to be consistent with which sensory alteration?

Sleep deprivation

Normal signs of aging

Dementia

Delirium

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Sleep deprivation is incorrect. While sleep deprivation can cause confusion and disorientation, it is less likely to cause abrupt onset of altered mental status and hallucinations. Sleep deprivation typically results in gradual cognitive decline and fatigue rather than sudden changes.

Choice B Reason:

Normal signs of aging is incorrect. Normal aging can involve some cognitive decline, but it does not typically cause sudden and severe symptoms like hallucinations and significant disorientation. These symptoms are more indicative of an acute condition.

Choice C Reason:

Dementia is incorrect. Dementia involves a gradual decline in cognitive function over time and does not typically present with sudden onset of symptoms. While dementia can include hallucinations and disorientation, these symptoms usually develop progressively.

Choice D Reason:

Delirium is correct. Delirium is characterized by a sudden onset of confusion, disorientation, and changes in mental status. It is often triggered by acute medical conditions such as infections, including UTIs. Elderly patients are particularly susceptible to delirium, which can include symptoms like hallucinations and severe confusion.

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Correct Answer is A

Explanation

Choice A reason: Encouraging the patient to drink more fluids is a primary intervention for managing thick respiratory secretions. Adequate hydration helps to thin the mucus, making it easier to expectorate. Fluids such as water, herbal teas, and clear broths are particularly effective. The normal daily fluid intake for an adult is about 2-3 liters, depending on individual needs and health conditions.

Choice B reason: Getting a prescription for an antitussive agent is not the best initial approach for managing thick respiratory secretions. Antitussive agents are used to suppress coughing, which can be counterproductive when trying to clear mucus from the respiratory tract. Instead, expectorants or mucolytics are more appropriate as they help to thin and loosen the mucus.

Choice C reason: Teaching effective deep breathing is beneficial for overall lung health and can help in mobilizing secretions. However, it is not as immediately effective as increasing fluid intake for thinning thick secretions. Deep breathing exercises can be part of a comprehensive respiratory care plan but should be combined with other interventions like hydration.

Choice D reason: Changing the patient’s position every 2 hours is a good practice for preventing complications such as pressure ulcers and promoting lung expansion. However, it is not specifically targeted at thinning thick respiratory secretions. Positional changes can aid in the drainage of secretions but are secondary to ensuring adequate hydration.

A. The family priest B. Ethics committee C. Joint Commission D. The blood bank

Correct Answer is B

Explanation

Choice A reason: Consulting the family priest may provide spiritual support and guidance to the family, but it is not the most appropriate action for resolving a medical and ethical dilemma. The family priest may not have the necessary medical or ethical expertise to address the complexities of the situation

Choice B reason: The ethics committee is the appropriate body to consult in this situation. Ethics committees are composed of healthcare professionals, ethicists, and legal advisors who can provide guidance on complex ethical issues. They can help navigate the conflict between the parents’ religious beliefs and the medical necessity of the blood transfusion for the newborn. The committee can also ensure that the hospital’s actions align with legal and ethical standards.

Choice C reason: The Joint Commission is an accrediting body for healthcare organizations and does not provide direct assistance in individual patient care situations. While the Joint Commission sets standards for ethical practices, it is not involved in resolving specific ethical dilemmas at the patient level.

Choice D reason: The blood bank is responsible for the collection, testing, and distribution of blood products. While they can provide information about blood transfusions, they are not equipped to handle ethical conflicts related to the refusal of blood transfusions on religious grounds. The ethics committee is better suited for this role.

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A nurse is caring for an elderly client diagnosed with a urinary tract infection (UTI). The family reports an abrupt onset of altered mental status, disorientation, and intermittent hallucinations. The nurse would identify these signs to be consistent with which sensory alteration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is complaining of thick respiratory secretions that are difficult to clear. What should the nurse encourage the client to do to help clear those secretions?

Correct Answer is A

Explanation

The nurse is caring for a newborn requiring a life-saving blood transfusion. The parents are practicing Jehovah’s Witnesses and refuse the transfusion. Who would the nurse consult for assistance in this situation?

Correct Answer is B

Explanation

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