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 C

Explanation

Choice A reason: Apple juice is an appropriate choice for a full liquid diet. It is a clear liquid that provides hydration and some nutrients without putting strain on the digestive system. Apple juice is easily digestible and does not contain any solid particles that could be problematic for a client recovering from abdominal surgery.

Choice B reason: Smoothies can be included in a full liquid diet as long as they are well-blended and do not contain any solid chunks. Smoothies can provide essential nutrients and calories, which are important for recovery. They can be made with fruits, vegetables, and protein supplements to ensure a balanced intake.

Choice C reason: Mashed potatoes and gravy are not suitable for a full liquid diet. Although mashed potatoes are soft, they are not liquid and can be difficult to digest for someone on a full liquid diet. The gravy may also contain small particles or thickeners that are not appropriate for this diet. A full liquid diet is intended to include only foods that are completely liquid or will turn to liquid at room temperature.

Choice D reason: Chicken broth is an excellent choice for a full liquid diet. It is a clear liquid that provides hydration and some nutrients without adding any solid particles to the diet. Chicken broth is gentle on the digestive system and can help maintain electrolyte balance.

A. Encourage coughing and deep breathing. B. Elevate the client to a high Fowler’s position. C. Administer prescribed analgesic medication. D. Administer oxygen at 2 L/min.

Correct Answer is D

Explanation

Choice A reason: Encouraging coughing and deep breathing is important for postoperative care to prevent complications such as atelectasis and pneumonia. However, with an oxygen saturation of 85%, the immediate priority is to address the client’s hypoxemia. Once oxygen levels are stabilized, coughing and deep breathing exercises can be encouraged.

Choice B reason: Elevating the client to a high Fowler’s position can help improve lung expansion and ease breathing. While this is a beneficial intervention, it is not the first priority when the client’s oxygen saturation is critically low. Administering oxygen should be the initial step to quickly improve oxygenation.

Choice C reason: Administering prescribed analgesic medication is essential for managing the client’s pain, which can also help improve breathing patterns. However, pain management should follow the immediate correction of hypoxemia. Ensuring adequate oxygenation takes precedence over pain relief in this scenario.

Choice D reason: Administering oxygen at 2 L/min is the first action the nurse should take. With an oxygen saturation of 85%, the client is experiencing significant hypoxemia, which needs to be corrected promptly to prevent further complications. Oxygen therapy will help increase the oxygen levels in the blood and improve the client’s overall condition.

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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 on postoperative day 2 following abdominal surgery. The surgeon prescribes a full liquid diet. Which food choice would be contraindicated for this client?

Correct Answer is C

Explanation

A nurse is caring for a client who has returned to the unit following a surgical procedure of the abdomen. The client is complaining of pain 6/10. On assessment, the client’s oxygen saturation is 85%. Which action should the nurse take first?

Correct Answer is D

Explanation

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