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
by the client's
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Upon assessment, the nurse should recognize that the client is at risk for developing delirium as evidenced by the client's orientation.
Rationale:
Delirium is an acute confusional state characterized by disturbances in attention, awareness, and cognition. It can be triggered by infections, medications, or other acute medical conditions, such as the urinary tract infection (UTI) in this client. The client is displaying confusion about time and place, agitation, and an inability to focus, all of which are key signs of delirium. Additionally, reorientation worsens the agitation, which is typical in delirium, as patients often cannot tolerate attempts to correct their disorientation.
In contrast, dementia is a chronic condition with a gradual onset of memory loss and cognitive decline, and stroke typically presents with sudden neurological deficits, which are not observed in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Clients with paranoid personality disorder often have difficulty trusting others, so providing written information about their treatment plan allows them to review it at their own pace, which can help build trust.
B. Countertransference involves the nurse projecting their feelings onto the client, which is not appropriate for establishing a therapeutic relationship. The nurse should maintain objectivity and professionalism.
C. Splitting is more common in clients with borderline personality disorder, not paranoid personality disorder. Monitoring for defensive or suspicious behaviors is more relevant in paranoid personality disorder.
D. Isolation is not a beneficial intervention for clients with paranoid personality disorder. Social interactions may actually help the client develop trust over time if managed properly.
Correct Answer is B
Explanation
A. Disulfiram is used as part of alcohol abstinence therapy and is not appropriate during acute alcohol withdrawal. It causes an adverse reaction when alcohol is consumed, but it does not help manage withdrawal symptoms.
B. Chlordiazepoxide is a benzodiazepine used to manage alcohol withdrawal symptoms, such as anxiety, agitation, and seizures. It helps prevent withdrawal complications such as delirium tremens.
C. Buprenorphine is used for opioid withdrawal and maintenance therapy, not alcohol withdrawal. It would not be effective in managing alcohol withdrawal symptoms.
D. Bupropion is an antidepressant and smoking cessation aid, but it is not used to treat alcohol withdrawal. It is not indicated in the acute management of alcohol withdrawal symptoms.
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