A nurse is caring for an older adult client.

Exhibits

Complete the following sentence by using the list of options.

Upon assessment, the nurse should recognize that the client is at risk for developing
dropdown
as evidenced by the client's
dropdown

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Blood pressure Potential worsening: The blood pressure dropped from 114/64 mm Hg on Day 1 to 98/56 mm Hg on Day 2, indicating a potential worsening as it decreased.

Gait when ambulating - Potential worsening: The client's gait was noted to be uncoordinated when ambulating to the bathroom on Day 2, suggesting a potential worsening in motor coordination or balance.

Lithium level Potential worsening: The lithium level increased from 1.9 mEq/L on Day 2, exceeding the therapeutic range (less than 1.5 mEq/L), indicating a potential worsening due to lithium toxicity.

Urine amount and color - Potential worsening: polyuria is a sign of lithium toxicity.

Blurred vision Potential worsening: The client reports blurred vision and frequently rubs their eyes on Day 2, indicating a potential worsening of visual acuity or ocular health.

A. Clients cannot refuse take prescribed medications. B. Clients continue to have the right to privacy and confidentiality. C. Clients have the right to the least restrictive environment. D. Clients maintain the right to an attorney. E. Clients cannot withdraw consent after signing an informed consent form.

Correct Answer is ["B","C","D"]

Explanation

A. Clients have the right to refuse medication, as part of their autonomy and informed consent rights.
B. Clients retain their right to privacy and confidentiality, which are fundamental rights in healthcare and protected under various laws and regulations.
C. Clients have the right to the least restrictive environment necessary for their treatment, which supports their freedom and dignity.
D. Clients maintain the right to an attorney, ensuring their access to legal representation and support.
E. Clients can withdraw consent at any time, even after signing an informed consent form, as part of their ongoing right to informed consent and autonomy.

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Body system	Findings
Neurological	Impaired cognition

	Insomnia Seizures
Cardiovascular	Increased blood pressure Increased heart rate Diaphoresis
Gastrointestinal	Lack of appetite Vomiting
Musculoskeletal	Malaise Tremulousness

A nurse is caring for an older adult client. Exhibits Complete the following sentence by using the list of options. Upon assessment, the nurse should recognize that the client is at risk for developing dropdownas evidenced by the client's dropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

A nurse is talking with a newly licensed nurse about client rights while admitted to a mental health facility. Which of the following information should the nurse include? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

A nurse is caring for a client in an inpatient mental health facility. The client tells the nurse that the government is reading her mail. Which of the following responses should the nurse make?

A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?

A nurse is assessing a client who has post-traumatic stress disorder. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?

A nurse is caring for an older adult client.

Exhibits

Complete the following sentence by using the list of options.

Upon assessment, the nurse should recognize that the client is at risk for developing
dropdown
as evidenced by the client's
dropdown