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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A Reason:
Date of birth is an acceptable client identifier. The Joint Commission specifies that using the date of birth helps ensure accurate identification of the client. This identifier is unique to each individual and is less likely to be duplicated.
Choice B Reason:
Photograph identification is not typically listed as an acceptable identifier by the Joint Commission. While it can be useful in some settings, it is not one of the primary identifiers recommended for ensuring patient safety.
Choice C Reason:
Facility room number is not an acceptable client identifier. The Joint Commission explicitly states that room numbers should not be used as identifiers because they can change and are not unique to the individual.
Choice D Reason:
Client’s full name is an acceptable client identifier. Using the full name helps to accurately identify the client and match them with their medical records and treatment plans.
Correct Answer is D
Explanation
Choice A Reason:
“Delivers a low concentration of oxygen” is incorrect because a nasal cannula can deliver varying concentrations of oxygen depending on the flow rate set by the healthcare provider. The concentration can range from low to moderate, typically between 24% to 44%.
Choice B Reason:
“Delivers a constant rate of oxygen” is partially correct but not entirely accurate. While the flow rate can be constant, the key aspect is the specific concentration of oxygen delivered, which is more relevant to the client’s understanding.
Choice C Reason:
“Delivers a high concentration of oxygen” is incorrect because nasal cannulas are generally used for low to moderate oxygen delivery. High concentrations of oxygen are typically delivered through other devices like non-rebreather masks or high-flow nasal cannulas.
Choice D Reason:
“Delivers a constant flow of a specific concentration of oxygen” is correct. This explanation accurately describes how a nasal cannula works. It provides a continuous flow of oxygen at a specific concentration, which is adjusted based on the client’s needs and the healthcare provider’s prescription.
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