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 ["B","C","D","E"]
Explanation
A. Placing the client in a reclining chair is not recommended as it does not prevent wandering or falls and may even restrict movement leading to discomfort or pressure sores.
B. Putting locks at the top of doors can prevent the client from wandering outside, which reduces the risk of falls and getting lost, especially during the night.
C. Encouraging physical activity prior to bedtime can help in expending energy which may lead to better sleep and reduce restlessness and wandering at night.
D. Positioning the mattress on the floor can minimize injury from falls that may occur when the client attempts to get out of bed during the night.
E. Installing sensor devices on outside doors can alert the caregiver if the client attempts to leave the house, which is crucial for preventing wandering and potential falls.
Correct Answer is B
Explanation
A. Discussing the importance of confidentiality is important but should not be the first action.
Addressing immediate emotional needs and coping strategies takes precedence.
B. Identifying prior coping skills helps establish a foundation for managing the current crisis. It allows the nurse to build on existing strengths and provide support tailored to the adolescents'
individual needs.
C. Reviewing community resources is valuable but should come after addressing immediate emotional needs and identifying coping skills.
D. Initiating referrals may be necessary, but it should follow the identification of coping skills and immediate emotional support.
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