A nurse is caring for an older adult client.
Complete the following sentence by using the list of options.
Upon assessment, the nurse should recognize that the client is at risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Upon assessment, the nurse should recognize that the client is at risk for developing acute confusion or delirium as evidenced by the client's disorientation to time and place, inability to focus, agitation, and anxiety upon reorientation. These symptoms suggest a disruption in cerebral metabolism, which can be caused by a variety of factors such as infection, fluid or electrolyte imbalance, or medication side effects. It is crucial to identify the underlying cause to provide appropriate care and prevent further complications. The nurse's role includes monitoring the patient's mental status, ensuring safety, and implementing therapeutic interventions to create a calming environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administering medications, such as atropine, requires nursing judgment and assessment of the client's condition, which should not be delegated to assistive personnel.
B. Witnessing the client's signature on the consent form ensures that the client provides informed consent for the procedure and requires nursing judgment.
C. Assessing the client's condition after the procedure involves monitoring vital signs, level of consciousness, and potential adverse reactions, which require nursing assessment and judgment.
D. Assisting the client to ambulate after the procedure is a task that can be safely delegated to assistive personnel, as long as the client's condition is stable and there are no contraindications to ambulation.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"},"H":{"answers":"A"}}
Explanation
Electroconvulsive therapy (ECT) is contraindicated in the acute phase of alcohol withdrawal due to the increased risk of seizure activity.
Group therapy is anticipated as it can provide peer support, coping strategies, and psychoeducation, which are beneficial for individuals with alcohol use disorder.
Performing the Alcohol Use Disorders Identification Test (AUDIT) is anticipated to assess the severity of alcohol use disorder and guide treatment planning.
Methadone may be anticipated as part of the treatment plan for managing alcohol withdrawal symptoms and cravings.
Ordering a complete blood count and basic metabolic profile is anticipated to assess the client's overall health status and detect any abnormalities related to alcohol use.
A nutritional consult is anticipated to address the client's weight loss and minimal appetite, providing dietary recommendations and support.
Propranolol may be anticipated to manage autonomic symptoms of alcohol withdrawal, such as tremors and tachycardia.
Diazepam may be anticipated to manage alcohol withdrawal symptoms, including agitation, anxiety, and seizures.
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