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 B
Explanation
A. Echinacea may affect immune function but does not have a direct adverse interaction with fluoxetine.
B. St. John's wort is known to interact with fluoxetine by increasing the risk of serotonin syndrome, a potentially life-threatening condition. Clients should avoid using St. John's wort with fluoxetine.
C. Ginkgo biloba can interact with anticoagulants but does not typically cause a dangerous interaction with fluoxetine.
D. Soy protein does not have a known adverse interaction with fluoxetine.
Correct Answer is C
Explanation
A. While this question may provide some insight into the client's feelings, it is more focused on acceptance and may not fully assess their coping mechanisms.
B This is a practical question addressing the client's needs but does not directly assess the client's coping ability.
C. Asking about the impact of the stroke on the client's life helps assess their emotional response and coping mechanisms. It provides the nurse with a broader understanding of how the client is adjusting to their condition.
D. This question may put the client on the defensive or lead to feelings of guilt or frustration, which may hinder their coping process. The focus should be on understanding the client's emotional response rather than exploring blame.
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